Memory Melody Questionnaire
Tell us about your loved one so we can create a special song just for them. When the form is completed, just hit the “Create My Memory Melody” button at the bottom of this page.
🌟 SECTION 1 – About Your Loved One
1️⃣ What is your loved one’s name? (If they have a nickname they prefer, please include that too!) (Please note their last name will not be included in the song)
*
First Name
Last Name
Do they have a nickname or a term of endearment?
2️⃣ Year of birth and where were they born or where did they grow up? (This helps us weave in a sense of place that might feel familiar to them.)
3️⃣ Did they have an occupation or career? (Examples: Teacher, Farmer, Nurse, Military, Homemaker, etc.)
4️⃣ What hobbies, interests, or activities have they always loved? (Cooking, gardening, quilting, fishing, traveling, etc.)
5️⃣ Do they have any favorite sayings or phrases they’ve always used? (Optional, but fun to include if you have one!)
🎶 SECTION 2 – Music & Memories
6️⃣ What kind of music makes them light up? (Examples: Gospel, Country, Rock ‘n’ Roll, Big Band, Classical, etc.)
7️⃣ Do you want the singer to be male, female, or no preference.
*
8️⃣ What decade do they most connect to? (50s, 60s, 70s, etc.—think of their teens or young adult years.)
9️⃣ Do they have any special memories tied to music that you’d like mentioned? (Dancing at their wedding, singing in church, family road trips, etc.) Or share a happy memory that always brings a smile.
💕 SECTION 3 – Purpose of the Song
🔟 What do you hope this Memory Melody will bring to your loved one?
*
Calm and comfort
A smile and a spark of joy
Something to dance or move to
A way to remind them they are loved
Nighttime lullaby
Other (explain in the comment section below please)
Would you like a special message included in the lyrics? (Example: “You are safe,” “We love you,” “You are my sunshine,” etc.)
📬 SECTION 4 – About You
Your name
*
First Name
Last Name
Your email address (so we can send your Memory Melody)
*
example@example.com
Completely optional - but helpful information
How did you hear about Memory Melody™? (Helps us know how people are finding us.)
Comments or suggestions
My Products (please select what you want to order)
*
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Memory Melody Custom Song
A one-of-a-kind song crafted just for your loved one, blending personal details with heartfelt music to spark joy, comfort and connection.
$
95.00
Quantity
1
2
3
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5
6
7
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9
10
Optional Printable Lyrics Keepsake
Your song, lovingly designed with a decorative border - ideal for memory books, bedside frames or heartfelt gifts
$
20.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
🎵 When you’re ready, just click “Create My Memory Melody” to submit your order.
Your personalized song will go straight into production, and you can expect to receive it by email within 48 hours.
🎵 “Create My Memory Melody”
Legal Notice
Memory Melody™ songs are a custom creative service, made uniquely for each recipient. Because they are commissioned works, they are generally not subject to sales tax in most states, including California.
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