Baby Block (8" x 8") Donation Form

Fill out, print, and mail to:

Raphael's Refuge,  P.O. Box 341, Flatonia TX  78941-0341

Name of Donor
Street or Box *
City,State, Zip *
E-mail Address:*
Phone Number* - -
  - -


Please note that without an address, a receipt cannot be sent for tax purposes.
Your information will not be sold or shared with another organization.
Amount of Donation
Name of Baby**
Date of Death (if known) / /
Date of Birth (if applicable) / /

NOTE: If the name and address of the baby's parents are different from those of the donor, please type them in the space below. The parents will be notified of your donation.

City,State, Zip


Jane Smith

Baby Smith
July 2002 
Baby Known to God

Raphael's Refuge is a non-profit 501(c)(3) organization. Donations are tax-deductible to the extent allowed by law .