Virtual Memorial Referral Form

Virtual Memorial Referral Form

Please complete this form entirely to have your loved one lost to gun violence featured in the #202forPeace Virtual Memorial. If you have any questions or concerns please email: Jordan.Stewart1@dc.gov

Your Name**

How are you related to the victim?*

Select

Is the victims immediate family aware of this request?*

Select

Your Email:*

Your Phone Number:*

What agency/organization is hosting this event?*

Please write N/A if not applicable

Information for the Virtual Memorial

This information will be reviewed before being published on the #202forPeace website. We will not edit this information. It will accompany your loved ones photo on the Virtual Memorial.

On what date was your loved one lost to gun violence?*

At what age was your loved one lost to gun violence?*

What was your loved ones name?*

What would you like the community to know about your loved one?*

Help us to understand what was special about your loved one and reasons why they are missed.

Please attach a photo of your loved one here:*

Please ensure no one else is in the photo.

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse