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Section 1 : Child's Details
We are a UK charity and only operate within the UK
Parent/Carer/Legal guardian Name
*
In Memory of
*
Age of Child
*
Total number of siblings for this application (including step)
*
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IF YOU REQUIRE DIFFERENT DESIGNS PER SIBLINGS, PLEASE SUBMIT AN INDIVIDUAL APPLICATION PER DESIGN.
Name of sibling
*
Age of sibling
*
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Name of sibling
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Age of sibling
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Name of sibling
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Name of sibling
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Age of sibling
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Name of sibling
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Name of sibling
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Name of sibling
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Name of sibling
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Referred by
*
Organisation
*
Family Name
*
Date
*
Next
Section 2 : Design
WE CAN ONLY USE 25 IMAGES IN THE ENTIRE DESIGN.
We will use 25 photographs/images of your special design to create your very own personalised Memory Box * Please note that whilst we will do everything we can to make your memory box as personal as possible, some images are protected by copyright and so cannot be included in your design.
Top of Box
Click or drag files to this area to upload.
You can upload up to 10 files.
Special requests, for example - Do you want a particular photo/image put on a specific side of the memory box? Is there any wording you would like included e.g name, date of birth, a phrase/sentence that means something special to you: Please detail below: **Remember to attach all photos/images to the email with your order form**
Top of Box Wording/Dates
Image layout (how would you like the images to appear on the top of the box?)
Front of Box
Click or drag files to this area to upload.
You can upload up to 10 files.
Front of Box Wording
Image layout (how would you like the images to appear on the front of the box?)
Left of Box
Click or drag files to this area to upload.
You can upload up to 10 files.
Left of Box Wording
Image layout (how would you like the images to appear on the left side of the box?)
Right of Box
Click or drag files to this area to upload.
You can upload up to 10 files.
Right of Box Wording
Image layout (how would you like the images to appear on the right side of the box?)
Back of Box Wording
Back of Box
Click or drag files to this area to upload.
You can upload up to 10 files.
Image layout (how would you like the images to appear on the box of the box?)
Number of Images attached:
Selected Value:
0
To ensure we have received all of your precious memories, please tell us how many images you are e-mailing to us . Please note that we can accomodate a total of 25 images. When considering where to place your images, the longer sides of the box can fit up to a maximum of 9 and the shorter sides 5
Google Drive or Dropbox link
If you would prefer to use Google Drive or Dropbox for us to access your images, please paste the link in the box provided. (please ensure we have assess permissions.
What theme would you like? e.g. Butterflies, Stars (copy)
Would you like to change the background colour?
*
Please Select
Leave White
Yellow
Green
Blue
Violet
Red
Pink
Orange
Black
Brown
Cream
Grey
Use Image provided
Would you like Harvey Bear?
*
Please Select
Yes
No
Additional Message or information
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I agree that 'A Siblings Wish' may use images in advertising materials (Names and dates will be removed where possible)
*
Please Select
Yes
No
I understand that it will not affect my aplication if I choose not to allow images to be used
*
Please Select
Yes
No
I confirm that I am the legal parent/guardian of all children named on this application form
*
Please Select
Yes
No
Please deliver the Memory Box to:
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
You must be resident in the UK, we are a UK charity and only operate within the UK
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Section 3 : Family details
Family contact details will only be used for queries relating to this order
Family contact number
Family e-mail
Please check
That all information provided and any special requests are correct before submitting this order. This is so we can ensure that your finished memory box is as beautiful as you have imagined.
I agree that the information on this form can be passed to The Harvey Hext Trust’s suppliers in relation to this order. I understand that this information will not be passed on to any other third parties
*
Yes, I/We agree
I have read and understood the information regarding Data Control
*
Yes, I/We have read and understood the information regarding the Data Control
Would you like to be added to our mailing list?
Yes, I/We would like to be added to the mailing list
We will treat your personal data in accordance with our privacy policy.
Our Privacy Policy
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