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33 4th St NW,
Sioux Center, IA
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PROMISE BABY STORIES
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PROMISE BABY STORIES
I AUTHORIZE PROMISE COMMUNITY HEALTH CENTER TO FULL USE AND DISCLOSURE OF MY AND MY DEPENDENT'S NAMES, PHOTOS, AND INFORMATION ON THE FOLLOWING MARKETING MATERIALS.
*
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Promise CHC Website
Promise CHC Social Media
Promise Print Materials
I UNDERSTAND THAT I MAY REFUSE TO SIGN THIS AUTHORIZATION. MY OR MY DEPENDENTS MEDICAL CARE WITH PROMISE CHC WILL NOT BE AFFECTED UPON MY SIGNING OR MY REFUSAL TO SIGN. I UNDERSTAND THAT I MAY REVOKE THIS AUTHORIZATION AT ANY TIME EXCEPT TO THE EXTENT THAT PROMISE CHC ALREADY HAS USED MY PHOTO/VIDEO AND/OR INFORMATION.
PARENTS' FULL NAME
*
if you would like to leave your last name off any marketing then please just put first names
PARENT EMAIL
*
just one email please
PARENTS' HOMETOWN
BABY FULL NAME (first, middle, last)
*
If you would like to leave your last name off any marketing then please just put in first and middle name
BABY GENDER
*
MALE
FEMALE
BABY BIRTHDATE
MM slash DD slash YYYY
BABY TIME OF BIRTH
:
Hours
Minutes
AM
PM
AM/PM
BABY WEIGHT (lbs and oz)
BABY HEIGHT (in)
LOCATION OF BIRTH
*
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HOSPITAL
IF APPLICABLE WHAT HOSPITAL
WHAT PROMISE STAFF ASSISTED WITH PRENATAL APPOINMENTS?
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Midwife Kari Ney
Midwife Audra De Groot
Nurse Jenna Wynia
Nurse Jaclyn Schelling
MA Heidy Hernandez
MA Bibiana Lopez
WHAT PROMISE STAFF ASSISTED WITH LABOR/DELIVERY?
*
Midwife Kari Ney
Midwife Audra De Groot
Nurse Kris Tinklenberg
Nurse Jaclyn Schelling
Nurse Jenna Wynia
Nurse Katie Milbrathtra
Nurse Ashtyn Hoekstra
Nurse Makayla De Jong
SIBLINGS (NAME, GENDER AND AGE)
if you would like to leave your last name off any marketing then please just put in first name
WE WOULD LOVE TO HEAR ANY HIGHLIGHTS OR COMMENTS ABOUT YOUR BIRTH STORY. CHOOSE ONE OR MORE OF THE QUESTIONS BELOW TO ANSWER.
WHAT I APPRECIATED MOST ABOUT OUR PRENATAL CHECKUPS & APPOINTMENTS:
WHAT I APPRECIATED THE MOST ABOUT LABOR/DELIVERY & BIRTH EXPERIENCE:
WHAT WOULD YOU TELL OTHER PATIENTS CONSIDERING USING PROMISE FOR THEIR PRENATAL CARE?
WHAT WOULD YOU TELL OTHER PATIENTS CONSIDERING HAVING A HOME BIRTH?
PLEASE LET US KNOW IF WE COULD HAVE DONE ANYTHING BETTER.
PLEASE UPLOAD IMAGES YOU WOULD LIKE US TO USE IN THE PROMISE NEWS POST - IF YOU DO NOT SEND PHOTOS THEN WE WILL USE A PROMISE LOGO IMAGE
*
Accepted file types: jpg, png, pdf, Max. file size: 50 MB.
If you would like to share high res images or more images than what this upload will allow, please use Facebook messenger to message them to Promise with your name OR email to kgesink@promisechc.org!
If you had a professional photographer at your birth and need/want to tag them in your photos please type in their business name here:
WOULD YOU BE WILLING TO TAKE PART IN A VIDEO TESTIMONIAL?
*
yes
no thank you
YOUR SIGNATURE:
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