Nurture A Superhero Order Form | To The Moon And Back, Inc

Nurture A Superhero care packages provide carefully cultivated newborn take home packages for children with Neonatal Abstinence Syndrome (NAS). These are provided at discharge from hospitals across the state and are fully funded from grants and donations.

We have distributed more than 600 boxes since 2018 to families with children diagnosed with NAS. These have gone to some 56 partners across the state, and we would love to get you a box!

REQUEST A BOX

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Organization Name

Please provide the name of the organization that is requesting an NAS box. If individual, please just type "individual."

Contact Name

First

Last

Phone Number

Please include the direct phone number for the contact.

Contact Email

Email

Confirm Email

Box Type

# of boxes requested

Location for delivery:

Please provide an address for delivery.

Days of Week and Times available for delivery:

Please provide the availability for delivery.

Additional information that we should know:

Please provide any additional comments or delivery information here.

By requesting these boxes, I commit to store them safely and distribute them to caretakers of NAS babies.

I have read and acknowledge that once received I will be responsible for the care and distribution of these boxes..

Name

To The Moon And Back is a 501(c)3 Nonprofit. The Nurture A Superhero boxes are funded by donations. If you are able to, please consider making a donation to our charity to ensure that we can continue to provide these care packages.

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