Elementor Form – Pearls Memory Babies

Welcome! Let's get started.

NOTE: Only employees of a facility with Memory Care patients are eligible to apply.

I am an employee of the facility listed on this application.

Memory Care patients reside in this facility

Facility Information

First Name

Last Name

What is your job title at your facility?

Facility Name

Address Line 1

Address Line 2

Enter City

State

Zip Code

Delivery Information

Has this facility received a donation from Pearl's Memory Babies before? (Answering "Yes" does not disqualify.)

Yes No

Does this facility have a unit dedicated specifically to memory care? (A "no" answer does not disqualify.)

Yes No

Please provide the total number of memory care residents so that each resident diagnosed with memory care issues will receive a donation from Pearl's Memory Babies. (Our donations are specifically intended for only memory care patients at this time. If your facility cares for both memory care and non-memory care residents, we kindly ask you to provide only the count of memory care residents who have been diagnosed with Alzheimer's or Dementia.)

Please consider carefully: Do you have a person on staff who is heartful about delivering the babies to each patient individually and placing them in the residents' loving care?

Yes No

Pearl's Memory Babies would be unable to offer this opportunity without the generosity of our donors. Are you willing to take photos and/or videos of residents (ones having photo release waivers/permission) receiving their delivery and sharing the photos/videos with Pearl's Memory Babies within 7 days for various media distribution outlets, including social media, so that our donors can see how their donations are making a difference for your memory community?

Yes No

How do you envision this donation assisting your memory community?

Please tell Pearl's Memory Babies why you feel this donation is important for your memory care residents (multiple lines of text can be typed.)

Selection Process

Donation recipients are selected by Pearl's Memory Babies' Board of Directors and will be emailed at the address provided here if and when selected. Selected facilities will have 3 business days to confirm acceptance of selection, sign and return all requested waivers, and provide a count of memory care residents; otherwise the donation may be cancelled by Pearl's Memory Babies. Selected facilities may be announced on and "tagged", "shared", mentioned, etc. on multiple social media sites by Pearl's Memory Babies.

I understand

Pearl's Memory Babies

Pearl's Memory Babies- Delivery Application

Welcome! Let's get started.

Facility Information

Delivery Information

Selection Process