Grateful Families & Friends

Your information

Your name*

Please tell us how you'd like to be recognized*

Select or enter value

Email address*

Phone number*

Relationship to patient*

Select

Mailing address

Street address

Apt./Unit #

City

State

Zip

Information about your loved one

Patient name*

When referring to your loved one*

Would you like us to change the name of your loved one when sharing your story?

Select or enter value

Name you would like us to use instead

Would you like to recognize a care team member?

Please list the name(s) of any Hospice of Santa Cruz County staff and/or volunteers.

Share your story*

Feel free to write as much or as little as you would like. There is no wrong way to express your story.

Photos

Would you like to share a photo of your loved one?

Drag and drop files here or

Media Release

May we share your story publicly?*

Select

By answering "Yes", I grant Hospice of Santa Cruz County the perpetual rights to share with the public, my story and any associated photo(s) of me and/or my loved one that I have provided, on its website, social media, newsletters, print materials, or other presentations.

I understand that my contact information will not be shared outside of Hospice of Santa Cruz County.

I acknowledge Hospice of Santa Cruz County’s right to crop or treat a photograph and edit a video or written interview at its discretion. I also acknowledge that Hospice of Santa Cruz County may choose not to use my photo or interview at this time but may do so at a later date.

You are under no obligation to share your story publicly and can change your mind at any time by emailing info@hospicesantacruz.org.

Send me a copy of my responses

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