HOPE Remembrance Wall

HOPE Virtual Memorial Wall

We'd like to honor your loved one that has passed, so we have created a page to share. Please share an image, story and/or thoughtful message about your loved one. Please fill out all information below, including the photo consent form.
Name of Loved One*

First NameLast Name
Year of Birth

MonthDayYear
Date
Year of Death

MonthDayYear
Date
Please write a short Memorial
Upload a Picture Here:

Please use a file with a .jpg or .png at the end of the file name.
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Consent to Use Photos and Story

HOPE Dementia Support Groups would like to memorialize your loved one who has passed. In accordance with our privacy policies we will not utilize photographs, video or stories without your consent. We would like to ask for your consent to use photographs/videos/stories about your loved one. These photos/videos/stories will be used on the HOPE Memorial Wall on our website to memorialize him/ her; to commemorate who he/she was before and during their illness. HOPE Dementia Support Groups will take all steps to ensure these images/stories are used solely for the purposes they are intended. If you become aware that these images are being used inappropriately you should inform HOPE immediately. No images/stories will be used without your consent.
HOPE Dementia Support may use my photos/videos/stories to memorialize my loved one.*

I consentI DO NOT consent
UNSWORN DECLARATION
Submitter Contact*

First NameLast Name
Date of Birth

MonthDayYear
Date
Contact Number*
Contact Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am the designated personal representative, executor, administrator, next of kin, or other person who has authority under Washington State law to act on behalf of the decedent or the decedent’s estate. I declare under penalty of perjury that the foregoing statement is true and correct.
Signature

Clear
Today's Date

MonthDayYear
Date
9901 NE 7th Ave, Ste 212 Vancouver, WA 98685

360.513.5754 alwayshopeinfo@gmail.com
Should be Empty:

HOPE Virtual Memorial Wall

Consent to Use Photos and Story

UNSWORN DECLARATION

9901 NE 7th Ave, Ste 212 Vancouver, WA 98685