Little Hearts

Membership Form

Become a Little Hearts member today! There is no cost to join. Get access to all of our support services and connect with other parents just like you.

(* Denotes Required Fields)

Contact Information

Last Name of Parent, Guardian or Yourself (18 years or older): *
First Name of Parent, Guardian or Yourself (18 years or older): *
Facebook Name (if interested in our FB support group)
Mailing Address: *
City: *
State: *
Zip Code: *
Home Phone Number: *
Cell Phone Number:
Email Address: *
Second Email Address:
How did you learn about Little Hearts?
Facebook
Google
Heart Parent
Hospital
Link
Pediatric Cardiologist
Other
Membership status *
Yes, I'm already a member. These are changes/updates to my membership information.
No. I'm completing this form to become a member.

CHD Information

Name of Individual with CHD: *
Date of Birth (or due date) of individual with CHD: *
Date Diagnosed with CHD *
Name of Heart Defect(s): *
Name and Dates of Surgeries: *
Complications
Hospital / Surgeon: *
Siblings and Birth Dates:

Support Services

Check off additional support services you are looking for:
I will use the Discussion Board to meet other "heart" parents
Give out my email address to members looking for support
Subscribe me to Little Hearts News Email Group for CHD News, Events & Projects
Send me an invite to the Little Hearts Inc FB Discussion Group to my FB name provided above
I want to add my child's story and will use Little Hearts Stories of Hope Submission form.
Specify

Permission

I give Little Hearts, Inc. permission to release my contact information for parent matching. I understand that my personal information will not be released to mailing lists and advertisers and is kept confidential. If you agree, please enter your electronic signature and date below:
Electronic Signature *
Date *
After completing our membership form, you will receive an email to the email address provided. Check your spam folder if you didn't receive one. For updates on your heart child, email address change, etc., please use this form.

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Become a Member Arrow
  • No cost to join
  • Access to support services
  • Connect with other parents
Share your Stories of Hope Arrow

Have a baby that is newly diagnosed with a CHD? Read our stories of HOPE from other people just like you.

Little Hearts, Inc.

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