Legacy Voices Program Enrollment Form

Legacy Voices Program Enrollment Form

Complete this form to start preserving your memories and stories with our support.
Client Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
City
State
Participant Details
Who is this service for?

Other (please specify)
Participant Name (if different from above)
Program Services
Select the services you wish to participate in:
Preferences
Preferred format for sessions
Preferred timeline for sessions
Background Information
Please share your story and goals for participating in this program.
Health & Sensitivity Considerations
Please note any special considerations (e.g., health condition, energy levels, accessibility needs).
Emergency / Support Contact
Support Person Name
Relationship to You
Support Person Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Consent & Permission
I consent to participate in the Legacy Voices Program and acknowledge that my information will be handled with care and confidentiality.
Media Consent
I give permission to share my recordings or written materials with designated family or loved ones.
I give permission for select portions of my story to be used for awareness or educational purposes (optional).
Disclaimer: This program provides emotional support and legacy preservation services and does not replace medical, legal, or mental health services. If you are experiencing a medical emergency, please call 911.
Signature
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Legacy Voices Program Enrollment Form

Client Information

Participant Details

Program Services

Preferences

Background Information

Health & Sensitivity Considerations

Emergency / Support Contact

Consent & Permission

Media Consent