SURVIVOR INFORMATION FORM
TO BE PLACED ON PARENTS OF MURDERED CHILDREN, INC'S MAILING LIST, PLEASE COMPLETE THIS FORM. If you do not have an answer to a question below, write no answer or n/a.
Please understand difficult questions will follow.
How did you hear about Parents of Murdered Children?
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Would you like to join the Chapter's Private Facebook Support Group - @pomclac?
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Yes
No
Parents Of Murdered Children – Los Angeles Chapter would like to respectfully honor your Loved One and, where applicable, bring attention to their unsolved case by displaying their photo. With your consent, the image may be used for commemorative and awareness purposes in various formats, including but not limited to our official website, social media platforms, memorial books, tribute videos, event poster boards, newsletters, and other related materials. This use is intended solely to memorialize your Loved One and to support ongoing public awareness efforts. Please indicate your preference below:
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Yes, I give my consent for my Loved One’s photo to be displayed as described above.
No, I do not give my consent for my Loved One's photo to be displayed as described above.
Survivor's Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone ONLY
Please enter a valid home number.
Mobile Phone ONLY
Please enter a valid moble phone number.
Email
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example@example.com
Upload photo of Loved one here:
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Loved One's First Name
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Loved One's Middle Name
Loved One's Last Name
Survivor's relationship to loved one
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Loved one's gender:
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How old was your loved one?
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Loved one's date of birth:
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MM-DD-YYYY
Loved one's date of death:
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MM-DD-YYYY
Cause of death:
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Cemetery where your loved one is buried?:
One link to an article about story.
Circumstances of murder:
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City and state in which murder occurred:
Is case unsolved? (Yes or No)
Case Number
Police Department
Detective(s) Name
Detective(s) Phone Number:
Detective(s) Email:
Courthouse
District Attorney's Name
District Attorney's Phone Number
District Attorney's Email
Court Advocate(s) Name:
Court Advocate(s) Phone Number:
Court Advocate(s) Email:
Upload perpetrator photo here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Perpetrator's Name:
First Name
Last Name
Perpetrator's Gender:
Perpetrator's Age:
Perpetrator Apprehended? (Yes or No)
Perpetrator Deceased? (Yes or No)
Sexual Assault (Yes or No)
Perpetrator charged with:
Perpetrator Convicted of/Pleaded Guilty to:
Perpetrator Sentenced to:
Thank you. We know these last several questions were difficult to answer. Please take time for self care during this time.
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Loved One's Middle Name
Should be Empty: