Little Hearts

20th Annual Picnic Medical Professionals Registration Form

Register today for our 20th annual Little Hearts Picnic.   Our event will take place on Sunday, June 5th at a facility located in the Hartford, Connecticut area. 

After you complete this form, visit the Merchandise Page of our website to pay your registration fee. Once both registration form and payment is received, directions and additional information about the facility and our event will be sent to you by postal mail.

Medical professional registration deadline is by Wednesday, May 24th.

(* Denotes Required Fields)

Name

Last Name *
First Name *

Contact Information

Street *
Town *
State *
Zip Code *
Email Address *
Telephone Number *

Attendee List

Please complete the name of those that you are registering and paying for online today. Those that you list today will have printed up name badges for the picnic.
Medical Professionals Name
Spouse
1st Child's Name
2nd Child's Name
3rd Child's Name
2nd Aunt's Name
3rd Aunt's Name
Other - Name & Relationship
Other - Name & Relationship
Other - Name & Relationship
Other - Name & Relationship
Payment *
Yes I would like to pay by credit card

Next Step in Registration is Payment

Thank you for registering for our 19th annual picnic. The next step is visiting the Merchandise page of our website to pay for your registration fee and to pre-order your Pictures of Hope.
Please Choose One: *
Yes I would like to make a $100 Sponsor Donation
No I would not like to make a $100 Sponsor Donation
If you selected "Yes," please visit the Merchandise page of our website. Must be received by May 24th to be displayed at the picnic.
Thank you for your picnic registration. Once we receive your payment, directions will be sent to you by postal mail.

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Little Hearts, Inc.

P.O. Box 171, Cromwell, CT 06416
Phone/Fax (860) 635.0006  Toll Free 866.435.Hope
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