1)  Were you able to donate your baby's umbilical cord blood?  Yes     No

1a)  If no, please explain and stop here. 

2)  Was Rayni Day Miracles, Inc. helpful in coordinating the donation?  Yes    No

2a)  If no, please explain. 

3)  Which cord blood bank did you donate your cord to?  Cryobanks Intl. St. Louis Cord Blood Bank Other   

3a)  If other, please specify. 

3b)  Was your experience with the cord blood bank a positive one?  Yes     No

3c)  If no, please explain. 

4)  Do you have any suggestions on how Rayni Day Miracles, Inc. could help make the process easier? 

5)  Will you suggest cord blood donation to your friends and family?  Yes     No

5a)  If no, please explain. 

Rayni Day Miracles, Inc. would like to acknowledge your gift in several ways.  We will not do so without your permissions.  Please complete the following questions so we can thank you for your donation.

1)  Would you like your first name and the first name of your baby listed in our annual newsletter?  Yes     No

1a)  If so, please provide the first names of anyone you want listed and specify their relationship to the donor. 

2)  Would you like a picture of your baby (with first name, month and year of birth only) posted on our website?  Yes     No

You can view other postings on our Donor page.  Please email a picture or send by mail with first name, month and year of birth.

2a)  Would you like Rayni Day Miracles to send an email to a list of addresses you provide acknowledging your baby's gift and providing a link to their picture that is featured on the Rayni Day Miracles, Inc. website?  Yes     No

If so, please provide us with a list of email addresses. 

3)  Would you like your doctor, nurse or midwife listed on our website?  Yes     No

You can view other posting on our Participating Doctors Page

If yes, please provide us with an email address or phone number of your doctor so that we may get their permission. 

4)  Rayni Day Miracles, Inc. sends a small gift to their donors on their first birthday acknowledging the gift they've given.  Can we plan on sending a gift to your child?  Yes     No

If yes, please provide the following:  Child's First Name   Last Name

                                                              Mailing Address 

                                                                City   State    Zip Code 

                                                                  Birth date 

Our organization would like to continue to include you in our activities.  We will include you on our email and mailing list unless you specify otherwise.  Following are several questions regarding your decision on future involvement. 

1)  Would you like to receive our annual newsletter by Email Regular Mail Neither

2)  Would you like to receive email alerts when our website is updated?  Yes     No

3)  Would you like to help by promote cord blood donation by distributing brochures to individuals and/or doctors' offices?

 Yes     No

3a)  If you answer yes, please provide your phone # so that we can contact you regarding the number of brochures you will need and the name of doctors'/organizations/individuals you plan on giving them to. 

Thank you for your time and thank you so much for your precious gift.