MMIP Memorial Submission Form
Please complete the form below for review by Empowerment Advocate staff for inclusion in the upcoming MMIP Memorial in Anchorage, Alaska.
Submitter Information:
Full Name
*
First Name
Last Name
Relationship to loved one
*
e.g., parent, sibling, friend, advocate
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Preferred method of contact
*
Phone
Email
Mail
I affirm that I have the authority and consent to submit the above name.
*
Please Select
Yes
No
Loved One’s Information
Full Legal Name
*
First Name
Last Name
Name they were known by
Nickname, Indigenous name, chosen name, etc.
Date of Birth
*
-
Month
-
Day
Year
Date Missing or Deceased
*
-
Month
-
Day
Year
This date can either be exact or estimated.
Community/Tribal Affiliation
If known and family wants included
Location Missing From / Last Seen
*
Current Status
*
Please Select
Missing
Murdered
Unresolved
Suspicious Death
Verification Information
Please feel free to provide as much information as possible
Case Reference Information (one or more of the following):
*
Law enforcement case number, Missing person report number, Media link(s) confirming missing/murdered status
Memorial Inclusion Preferences
How would you like your loved one's name displayed?
*
Full name, shortened, Indigenous name, ect.
Do you want your loved one's Tribal/community affiliation shown?
*
Please Select
Yes
No
Consent & Acknowledgement
The information provided is true to the best of my knowledge.
Empowerment Advocate has permission to use and display the information provided exclusively for the MMIP memorial.
I understand that submissions will be reviewed and verified before inclusion.
I consent to notifications about memorial updates/events.
Signature
*
Continue
Continue
Should be Empty: