The Congenital Heart Defect Awareness Quilt Project, Inc.
The CHD Awareness Quilt Project Block Dedication Form
Each heart block included on the CHD Awareness Quilt Project is dedicated to a child or adult affected by Congenital Heart Defects.  Each block is personalized with name, birth date,  and abbreviated heart defect diagnosis. Appliques are added to those who have a pacemaker, had a transplant, or have become an angel. There is no cost to be included in the project. Please fill out form below and submit as much information as possible.

Once a block has been completed you will receive notification by email, including a picture of the completed block. Due to the volume of requests and the personalization of each block, we cannot put a time frame on how long it will take for a block to be completed and put into a quilt. If you choose to make your own block, please specify that in the comment section and visit our block directions page.

By filling out the dedication form, you are granting permission for your child's name (or your name) to appear on the CHD AWARENESS QUILT Project.  The Quilts will be on display at public events.  If you do not want your child's last name on the quilt, please indicate that as well. None of the information provided will be sold or used for any other purpose than the CHD Awareness Quilt Project.

NOTE:  Recently, we have been receiving a large number of requests for blocks to be placed on the same quilt as another person.  While we will try our best, we cannot guarantee that this will happen. If the CHDers are  family members and the dedication forms are sent in at the same time, we will see to it that they are on the same quilt. We cannot guarantee that a block will be in the same quilt as a friend's block.

 *Items marked with are optional. Information will be used to contact you if we have questions concerning your block request, to email photo of completed quilt block, and information regarding the CHD Awareness Quilt Project and the Quilts. Please see our Privacy Policy for more information.
Name for block:
Parent/Guardian :
Gender:
*Street Address:
*City, State, Zip:
Country:
*Phone:
*Email:
Diagnosis (abbreviated, list all):
Birthdate:
Date of death (if applicable):
Pacemaker? If yes, date of inplant:
Transplant? If yes, date of transplant:
Comments: Please include any information  that can assist us in personalizing a quilt block, such as favorite color, cartoon character, hobby, etc.
Share your personal website with us:
How did you hear about the CHD Awareness Quilt Project?
Click here to view samples .
The Congenital Heart Defect (CHD) Awareness Quilt Project, Inc. is a non-profit (501c3) organization  The Congenital Heart Defect Awareness Quilts and contents of this site are Copyright 2000-2013. The Congenital Heart Defect (CHD) Awareness Quilt Project. All rights Reserved.
Passionately Promoting CHD Awareness 
            ...One stitch at a time
The Congenital Heart Defect Awareness Quilt Project, Inc.