Bereavement Photo Request - Capturing Hopes

Infant Loss Request Forms

Please scroll to the end for all hospitals outside of the locations below.

Novant Health Forsyth Medical Center

Winston Salem, NC

Fill out the form

Moses Cone Women's Hospital

Greensboro, NC

Fill out the form

Other North Carolina Hospitals

Covering hospitals within approx 1 hour from the Triad of North Carolina

Fill out the form

All other hospital locations

If you are located outside of the Triad of North Carolina, we will be happy to find you a bereavement photographer. Fill out the form below as far out as you can and we will work on it. For immediate requests you can text 336-493-3778 with your name and the hospital and city you are located in for the session.

We cannot guarantee we will find one in time, but we will do our best!

Thank you for signing the Little Lights consent form. Your photos will be emailed to you within 2 weeks. If you need a specific photo prior to that time, please email us at bereavement@capturinghopesphoto.org

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Photographer's Name

Hospital Name

City and State of Hospital

First Name

Last Name

Email (your photos will be sent here)

Phone

Baby's name (optional)

Gestational age of infant at birth

Photography Permissions: I hereby grant permission for the medical staff member or photographer to photograph my infant and any family members included in the photography session. Photography Permissions Signature

Support Person Permissions: If the photographer is not part of the medical staff at the hospital that I deliver at, I hereby grant permission to allow them to enter the hospital as a guest of mine and consider them a necessary support person during my loss. Signature

Bereavement photography and video consent. Bereavement photos and videos are used to further train the bereavement community in the importance of photography during child loss. Education in this area is important for hospital staff and photographers to be able to continue to provide this free support program to grieving families. Please sign below if you consent to allow your photo session to be used to educate and train within the bereavement community. This includes in print form, website, social media platforms, bereavement education conference material, and media. I hereby understand that at no time will my baby or family's private information be used publicly during education and training for bereavement photography. Please sign below.

Is there anything else we should know?

Little Lights Photography

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