Wave of Light Registration

To include your precious child in our Wave of Light ceremony,
please complete and submit the following information by 10 a.m. on Friday, October 11.

Parent/Guardian First Name*

Parent/Guardian Last Name

Your Address*

Phone*

Email*

In Memory Of*

Date of Birth or Due Date*

Date of Passing

CONSENT & AUTHORIZATON*

By submitting this information, I confirm that I have the authority to provide this information for public use in conjunction with Coffey Health System's Wave of Light ceremony.

UserEmailAddress*

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