Survivor Information Form

PARENTS OF MURDERED CHILDREN

SURVIVOR INFORMATION FORM
Please understand difficult questions will follow.
If you do not have an answer to a question below, write no answer or n/a.
Survivor's Name (Person filling out this form)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone ONLY
Please enter a valid home number.
Mobile Phone ONLY
Please enter a valid moble phone number.
Email*
example@example.com
Loved One's First Name*
Loved One's Middle Name
Loved One's Last Name
Loved one's date of birth:*
MM-DD-YYYY
Loved one's date of death:*
MM-DD-YYYY
Loved one's gender:*
How old was your loved one?*
Survivor's relationship to loved one*
Parents Of Murdered Children – Los Angeles Chapter would like to respectfully honor your Loved One and, where applicable, bring attention to their unsolved case by displaying their photo. With your consent, the image may be used for commemorative and awareness purposes in various formats, including but not limited to our official website, social media platforms, memorial books, tribute videos, event poster boards, newsletters, and other related materials. This use is intended solely to memorialize your Loved One and to support ongoing public awareness efforts. Please indicate your preference below:*

Yes, I give my consent for my Loved One’s photo to be displayed as described above.No, I do not give my consent for my Loved One's photo to be displayed as described above.
Upload photo of Loved one here:

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City and state in which murder occurred:
Cause of death:*
Circumstances of murder:*
One link to an article about story.
Cemetery where your loved one is buried?:
Is case unsolved? (Yes or No)
Case Number
Police Department
Detective(s) Name
Detective(s) Phone Number:
Detective(s) Email:
Courthouse
District Attorney's Name
District Attorney's Phone Number
District Attorney's Email
Court Advocate(s) Name:
Court Advocate(s) Phone Number:
Court Advocate(s) Email:
Upload perpetrator photo here:

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Perpetrator's Name:

First NameLast Name
Perpetrator's Gender:
Perpetrator's Age:
Perpetrator Apprehended? (Yes or No)
Perpetrator Deceased? (Yes or No)
Sexual Assault (Yes or No)
Perpetrator charged with:
Perpetrator Convicted of/Pleaded Guilty to:
Perpetrator Sentenced to:
Would you like to join the Chapter's Private Facebook Support Group - @pomclac?*

YesNo
How did you hear about Parents of Murdered Children?*
Thank you. We know these last several questions were difficult to answer. Please take time for self care during this time.
For POMC LA Office Use Only

NationalMaster ListEmail InputWebsiteUnsolvedUnsolved DocumentPhoto AuthorizationMaster Photo FolderGoogle Photo AlbumCourt AccompanimentFacebook Support Group
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PARENTS OF MURDERED CHILDREN

Please understand difficult questions will follow.