The CHD Awareness Quilt Project Block Dedication Form
Please Note: By filling out the dedication form, you are granting permission for your child's name (or your name) to appear on the CHD AWARENESS QUILT Project as well as the CHD HONOR ROLL (which is on-line). The Quilts will be on display at public events. The CHD Honor Roll is on the world wide web with access to all. If you do not want to be included on the CHD HONOR ROLL, please indicate as much in the comments section of the registration form. If you do not want your child's last name on the quilt, please indicate that as well.
None of the information provided will be sold or used for any other purpose than the CHD Awareness
Quilt Project.
Each heart block included the CHD Awareness Quilt Project is dedicated to a child or adult effected by Congenital Heart Defects. Each block is personalized with name, birth date, and abbreviated heart defect diagnosis. Appliques are added to those who have a pacemaker, had a transplant, or have become an angel. There is no cost to you to be included in the project. We ask that you fill out the form below and submit as much information as possible.
If you choose to make your own block, please specify that in the comment section. This will help us avoid duplicate blocks. Once a block has been completed for you or your child, you will receive notification by email, including a picture of the completed block. Due to the volume of requests and the personalization of each block, we cannot put a time frame on how long it will take for a block to be completed and put into a quilt. You can check the status of your block on our block status page.
If you are interested in making your own block, visit our block directions page
NOTE: Recently, we have been receiving a large number of requests for blocks to be placed on the same quilt as another person. While we will try our best, we cannot guarantee that this will happen. If the CHDers are siblings or family members and the dedication forms are sent in at the same time, we will see to it that they are on the same quilt. We cannot guarantee that a block will be in the same quilt as a friend's block.
The CHD Awareness Quilt Project is an International project designed to include people effected by Congenital Heart Disease world wide. We feel that having quilts solely dedicated to a Country, State, or Region would exclude others. Our goal is to promote Congenital Heart Defect Awareness. Congenital Heart Disease is a world wide disease and we need to promote awareness world wide.
If you have questions or comments concerning this, please contact us.
Name for block:
Parent/Guardian Name:
Gender:
*Street Address:
*City, State, Zip:
Country:
*Phone:
*Email:
Diagnosis (abbreviated, list all):
Birthdate:
Date of death (if applicable):
Pacemaker? If yes, date of inplant:
Transplant? If yes, date of transplant:
Comments: Please include any information on you or your child that can assist us in personalizing a quilt block, such as favorite color, cartoon character, hobby, etc.
Share your personal website with us:
How did you hear about the CHD Awareness Quilt Project?
*Items marked with * are optional. We will only use the information to contact you if we have questions concerning your block request, to send an emailed photo of your completed quilt block, and information regarding the CHD Awareness Quilt Project and the Quilts. Please see our Privacy Policy for more information.
Click here to view samples of some of some blocks we have made using the comments we have received in the Comments box. This page will load in another browser window.
