MMIP Memorial Submission Form
Please complete the form below for review by Empowerment Advocate Alaska staff for inclusion in the upcoming Alaska MMIP Traveling Memorial. Share the life story of your loved one and upload photos and a video to honor their memory if you would like their profile included in the "Alaska MMIP: We Remember" app. If you have any issues uploading videos or photos, please contact us at: Cynthia@empowermentadvocate.com
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. If you do not have a case number or media link, you can type in ‘Other,’ and we will reach out to you for additional information.
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
Alaska MMIP: We Remember App
If you would like your loved one’s profile to be included in the Alaska MMIP: We Remember app, please complete the information below. The app is designed to accompany the traveling memorial, but it is not required in order for your loved one to be included on the memorial itself. If you choose to have your loved one’s profile added to the app, a QR code will be placed next to their name on the traveling memorial, linking directly to their profile and the information you provide. If you have any questions, please email cynthia@empowermentadvocate.com.
Please write the life story of your loved one.
Upload up to 5 photos of your loved one (JPEG, PNG formats).
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload 1 video of your loved one (MP4, MOV formats).
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Consent & Acknowledgement
The information provided is true to the best of my knowledge.
I am a family member, close relative, or have permission from the family to submit this request.
Empowerment Advocate has permission to use and display the information provided exclusively for the Alaska MMIP Traveling memorial and/or Alaska MMIP:We Remember app.
I understand that submissions will be reviewed and verified before inclusion.
I consent to notifications about memorial updates/events.
Signature
*
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