Personalized Song Request Form

Why create a song? To celebrate & preserve your loved one's LIFE!! Families gain a bit of healing as they navigate the tough road of life with neuro changes.

What to expect: Your families free gift of song will be ready in approx. 15 days. The song is emailed as an Mp3 to share & enjoy. You will also receive a printable version of the lyrics that can be framed, etc. Anyone who is kind enough to donate, is eligible to add a micro SD card with your song that we mail to you. It plays on the Healing Headset or other compatible devices. Learn more or donate at: www.mymemoryworx.org

Let's begin the LIFE STORY SONG. Please be THOROUGH in your answers:

 You must click NEXT BUTTON for the final page. Once submitted, a confirmation email will be sent. Remind others that life IS a little better when put to music!!

"My gift is my song and this one's for you."
~Elton John~

We do prefer to receive donations upfront. If this simply is not workable, consider donating via a check. Checks can be made payable to: MyMemoryWorx and then mailed to our managing foundation at:

Southeastern Illinois Community Foundation

PO Box 1211

Effingham, IL 62401 US

217.342.4988

admin@southeasternillinois.org