Tiny Footprints Order Form

Tiny Footprints Order Form

By completing this form, you are giving permission to Antelope Valley Healthcare District to place your child's/children's medallion(s) on a public display wall. Payments will be made to the Antelope Valley Medical Center Foundation.
Your Name

First NameLast Name
Baby's Name

First NameLast Name
Baby's Gender

MaleFemale
Baby's Date of Birth

MonthDayYear
Date
Hospital Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Upload copy of child's footprint

Cancelof

Tiny Footprints

Silver Medallion

Includes two (2) medallions with name and birth date. One (1) is placed on a permanent display wall inside the Women and Infants Pavilion and you receive a duplicate keepsake.

$200.00 Quantity

Crystal Ornament

Includes one (1) keepsake ornament with name and birth date and one (1) silver medallion that is placed on a permanent display wall inside the Women and Infants Pavilion.

$200.00 Quantity

Additional Crystal Ornament

$60.00 Quantity

Additional Silver Medallion

$60.00 Quantity

Total

$0.00

Credit Card Information

First Name / Company

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Signature
Should be Empty: