Make New Memories Application

Make New Memories Application

VictimsFirst
Our Make New Memories program is open to all victims of mass violence. You can apply for yourself or nominate a survivor or the immediate family member(s) of a victim of mass violence. To apply, please fill out the form below.

We will respond to you within one week of receiving your application.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Are you applying for yourself or someone else?*

MyselfSomeone Else
If applying for someone else, what is their NAME?

First NameLast Name
Name/Location of Mass Violence Incident (i.e., Pulse Nightclub/Orlando)
Briefly Describe Your New Memory Request*
Ideal Date for New Memory

MonthDayYear
Date
Is Travel Required?

YesNo
How many people will participate?
Should be Empty: