MyImpactPage - Red Nose Limited

Welcome to Heart Strings. We’re so sad that you have reason to be joining our community of bereaved family members, but we are glad that you have found us.

If you don't have the capacity to fill this out right now, please submit your contact details, and we will be in touch.

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Account

Username

Required

	Username must not start with space
	Username must not end with space
	Username must not have two or more spaces in a row

Password

Required

	Password needs to have at least 12 characters.
	Password needs to have at least one upper case character.
	Password needs to have at least one lower case character.
	Password needs to have at least one number.
	Password cannot be on a list of commonly-used passwords.

Confirm Password

Required

	Password needs to have at least 12 characters.
	Password needs to have at least one upper case character.
	Password needs to have at least one lower case character.
	Password needs to have at least one number.
	Password cannot be on a list of commonly-used passwords.

Name Fields

First Name Required
Last Name Required

Address

Address line 1 Required
Address line 2
City Required
Country Required
State / Province Required
Zip / Postal Code Required
Email Address Required

Phone Numbers

Required Please enter at least one phone number

Home Phone
Work Phone
Work Extension
Cell Phone
Phone Preference

Text Messaging

I want to receive text messages on my cell phone.
Cell Phone Number

Misc Fields

Region

Who are you remembering?

Please include their full name Required

Please select your special date of remembrance: mm/dd/yyyy

Please share the name(s) and date(s) of any additional children or babies you are remembering (more than one can be included here):

Your relationship to the little one(s) you are remembering

YOUR HOUSEHOLD MEMBERS (details will be used for your annual remembrance card)

Names of adults living in your household, and their relationship to the baby or child you are remembering

Names of children living in your household, and their relationship to the baby or child you are remembering

DIGITAL REMEMBRANCE TILES

At certain times in the year, we offer personalised special occasion tiles to all members of our community. As a Heart Strings member, you’ll be the first to see each of our designs. You can opt-in below to automatically receive any or all the tiles, personalised with the name(s) of your little one(s). Your tile will be included in the first upload to the Facebook albums for each occasion. An example of recent tiles is below:

Your little one's name as you would like it displayed on your tile (please leave blank if you would like to opt out)

No tile please - please select here to opt out of a remembrance tile

Please select the tile(s) would you like to opt in for:

Christmas

Holiday Season

Mother's Day

Father's Day

Would you like your child's name to be included in the quarterly Heart Strings newsletter's remembrance video? Required

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