GLO Preemies Program Registration!
Welcome to the GLO Preemies Program Registration! This form is the first step for Black NICU families to access resources, support, and community tailored specifically to your needs. By signing up, you'll have the opportunity to receive telehealth services, a care box shipped directly to your home, weekly blogs, and much more, all designed to support you through your NICU journey.

Please Note: This program is specifically designed for Black families with NICU experiences. Our mission is to provide targeted support and resources to address the unique challenges and disparities faced by Black NICU families.  
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Email *
Parent/ Guardian Full Name:        *
Preferred Name (If any): 
(This is name you identify with providing this allows staff to address you appropriately)
Contact Information: Email Address *
Phone Number: *

Address for Care Box Shipment: Address, City, State, and zip code

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NICU Hospital (Hospital Name): *
Gestation of Pregnancy at Birth: *

Age of NICU Child:
 *
Do you consent to Telehealth Services? *
Would you like a Care Box shipped to your home? *
We like to add something extra to each care box. Which Care Box type for the baby would you like shipped to your home? *
Would you like to become a member of our website to receive weekly blogs and more delivered to your email?
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How did you hear about the GLO Preemies Program?
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Is there anything specific you hope to gain from joining the GLO Preemies Program?
Privacy and Consent:

I understand that the information provided in this form will be used to deliver services and support through the GLO Preemies Program. I consent to the collection and use of this information for such purposes.  

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Required
Agreement to Terms:

I have read and agree to the Terms of Service and Privacy Policy.
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