After you submit this form, we will contact you within 48 hours to go over details. If you are only interested in emotional support, you only need to fill out section 1. If you are requesting financial assistance, we ask that you exhaust other options which may be available to you prior to applying for the financial assistance. If you need the application expedited or would like an update on the status of your application, please contact us at (253) 200-0944 or office@thetearsfoundation.org.

Request for Assistance
Requested Assistance (choose all you wish to receive) *
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Cause of Death
 
Child/Baby's Ethnicity (for statistical purposes only)
 
Was this pregnancy selectively terminated? *

Parent Information (section 1)

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Additional Information for Financial Assistance only (section 2)

If you are requesting emotional support only, you do not need to fill out this section and may go directly to the end of the form and click submit.

Financial Assistance for Infant Funeral Program Guidelines (only): Baby is between 20 weeks gestation to 1 year old, pregnancy was not selectively terminated, it has not been more than 30 days after funeral service (current funerals). If you do not qualify under these guidelines, you may still utilize other TEARS services. Contact TEARS For more assistance (253) 200-0944 or office@thetearsfoundation.org

Annual Household Income
So we can best assist you with your needs, fill out any other resources that may be available (choose all that may apply)
Have you already met with a funeral director?
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Type of Services

Supplemental Questionnaire for SIDS or sleep related deaths only (section 3)

Please fill out for potential SIDS or sleep related infant deaths. If child's death was not related to these possible causes, you may skip to the end and select submit. This information will aid us in future research & data to help prevent infant loss. Thank you for supporting these efforts.Our hearts go out to you at this time of devastating loss. Thank you so much for providing this information and helping us in our attempt to research and reduce SIDS and infant deaths. You are not alone and if you would like additional emotional support, please contact us at 253-200-0944.

Where was your baby sleeping at the time of death
In what position was your baby sleeping?
If your baby was sleeping in their crib, did the crib have loose blankets, stuffed animals, bumper pads, or pillows in it?
Was your baby sleeping with an adult?
Does anyone in the household smoke cigarettes? (Choose yes, even if they smoke outside only)
Save & Return Account (optional)
New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish. The account you establish is only for this form.