Hospital Order Form Thank you for using the Second Stork on-line order form. This form allows us to insure accuracy and timeliness in supplying hospitals with critical care items for new parents in need. Note that all order quantity boxes REQUIRE completion (even if order quantity is “0”), then simply hit SUBMIT. A volunteer will be in touch soon regarding your delivery. Name of hospital***select your hospital**Abbott Northwestern, MinneapolisBuffalo Hospital, BuffaloCambridge Medical Center, CambridgeCentraCare MelroseCentraCare MonticelloCentraCare Saint CloudChildren’s Hospital, MinneapolisChildren’s Hospital, Saint PaulCuyana Range Hospital, CrosbyDistrict One Hospital, FaribaultDouglas County Hospital, AlexandriaEssentia Health, VirginiaFairview Lakes Medical Center, WyomingFairview Northland Health Services, PrincetonFairview Ridges, BurnsvilleFairview Riverside/St. Mary’s, MinneapolisFairview Southdale, EdinaFirstlight Health System, MoraGrand Itasca Hospital, Grand RapidsHCMC, MinneapolisHutchinson Health, HutchinsonLake Region Health Care, Fergus FallsLakeview Memorial Hospital, StillwaterLakewood Health Systems, StaplesLifecare Medical Center, RoseauMaple Grove Hospital, Maple GroveMasonic Children’s Hospital, MinneapolisMayo Clinic Health System, FairmountMayo Clinic Health System, MankatoMayo Clinic Health System, New PragueMayo Clinic, Albert LeaMayo Clinic, AustinMayo Clinic, Red WingMayo Clinic, RochesterMercy Hospital, Coon RapidsNorth Memorial, RobbinsdaleOlmstead Medical Center, RochesterOwatonna HospitalPark Nicollet Methodist Hospital, St. Louis ParkPerham Methodist HospitalRainy Lake Medical Center, International FallsRange Regional, HibbingRedwood Area Hospital, Redwood FallsRegina Medical Center, HastingsRegions, Saint PaulRiverview Health, CrookstonRiverwood Health Care Center, AitkinSanford Health, BemidjiSanford Health, Thief River FallsSt. Francis Regional Medical Center, ShakopeeSt. Gabriel’s Hospital, Little FallsSt. John’s, MaplewoodSt. Joseph’s Hospital, BrainerdSt. Joseph’s Hospital, Park RapidsSt. Joseph’s, Saint PaulSt. Lukes Hospital, DuluthSt. Mary’s Medical Center, DuluthTri County Hospital, WadenaUnited Hospital, Saint PaulUnited Hospital District, Blue EarthWoodwinds, WoodburyOther Items Requested (Insert quantities. All fields required.) Play Yards with bassinet attachment and sheet* For new parents with no other option to secure a safe place for newborn to sleep. Quantities are limited, please order only the number that corresponds to parents that would have NO other option or resource to secure a safe place for their newborn to sleep. Layettes with one receiving blanket, onesie, sleeper and accessory – enter TOTAL requested* for new parents with no new clothing for their newborn as they leave the hospital; supply is limited and, as reported by most hospitals, typically the number of parents that have no newborn clothing is less than half the typical number that need diapers (below). We will deliver an assortment of sizes, or if our availability allows, you can specify the quantity of sizes you prefer below. Total number of layettes may not exceed SIX. SIZE 0-3 months/SIZE 1 layettes (generally for 8# and larger babies)* SIZE NEWBORN layettes (generally for 5-8# babies)* SIZE PREEMIE layettes (generally for babies under 5#)* Diaper Bags of 100 diapers, wet wipes, related items – enter TOTAL requested* for new parents with limited or no financial resources to secure a supply of diapers and wet wipes in first few weeks. We will deliver an assortment of bags in different sizes, or if our availability allows, you can specify the quantity of sizes you prefer below: Bags of 100 SIZE 1 diapers (for 8# and larger babies)* Bags of 100 SIZE NEWBORN diapers (for babies 5-8#)* Bags of 100 SIZE PREEMIE diapers (for babies under 5#) Pacifier supply bag of 12 newborn pacifiers* for hospital staff to keep on hand to distribute as they deem appropriate Bottle supply bag of 12 bottles* for hospital staff to keep on hand to distribute as they deem appropriate Method of Delivery* Hospital will be sending a representative to pick up at Second Stork Hospital requests a delivery Other Specific hospital entrance door to meet staff for drop-off Days/hours available to accept delivery Please specify other method of delivery Contact Information Please give us the name and phone number of the person with whom our volunteers should coordinate the pick-up or delivery. Name* Email Address* Cell Phone* Pager if applicable reCAPTCHA Additional Notes If you have additional information or requests to forward to Second Stork, please note above.