2023 Annual Memorial Registration

Name*

First Last

I plan on attending virtually.

Yes
No

“This option to attend virtually allows you to view the service, but is not interactive. The link will be emailed to you upon registration”

Email*

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of loved one(s) who died by suicide

Your relationship to your loved one(s)

Important dates associated with your loved one(s), including birthdates, anniversaries, and/or date(s) of death

What, if any, emotional support needs might you have?

Will you need any physical assistance?

Number of people attending with you

Please include the names of the people attending with you

Would you like your loved one's name listed in the In Memoriam section of our program?

Yes
No

Would you like to submit something to the event program?

No, I do not want to share or include a submission in the program.
Yes, I would like to submit something to be printed in the event program but not shared aloud.
Yes, I would like to read my submission aloud.

If yes, please note that there is a 3-to-5-minute time limit for each submission. Submissions must be received by January 6th, 2023 at 5:00 pm. Submissions that are received after this deadline will not be included in the printed program.

If you would like to submit something to the program, please upload it here:

Max. file size: 50 MB.

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If you'd like to include a photo of your loved one in the Book of Remembrance, you can upload it here:

Max. file size: 50 MB.

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Would you like to make an optional donation to support Grief Support Services at Samaritans?

Donation Amount*

Credit Card*

Card Details

Cardholder Name

Dedicate Your Gift:

Who is your gift dedicated to?

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