Precious Prints Project Inquiry Form

Thank you for your interest in becoming a Precious Prints Project (P3) Health Care or Nursing Program Partner. Once you complete the information below, we will provide you with a Precious Prints Project Information packet that has all the information on how to get started!

Date

Name

First Last

Phone

Title/Position

How did you hear about the Precious Prints Project?

Name of the Health Care Facility or Nursing Program Name

Address of the Health Care Facility or Nursing Program Address (Street, City, State, Zip code)

Contact Person's Name for the Precious Prints Project (if different from above)

Contact Person's Email for the Precious Prints Project (if different from above)

Contact Person's Phone Number for the Precious Prints Project (if different from above)

What is the estimated number of deaths per year for children ages 0-21 at the Health Care Facility?

What is the estimated number of Precious Prints Kits (used to make the precious prints) that you will need each year for the Health Care Facility?

If you know which units at the Health Care Facility that you want to provide with Precious Prints Kits, please list them below (i.e., Labor & Delivery, Emergency Room, Pediatric Units)