Your Name *

First Name

Last Name

Phone *

(###)

###

####

Name of your Donor Hero *

First Name

Last Name

Donor's Date of Birth *

MM

DD

YYYY

Donor's Date of Death *

MM

DD

YYYY

CONSENT FOR USE AND DISCLOSURE *

Please fill out the following consent and disclosure form. By submitting this electronically signed consent form, you are granting consent for your hero’s name, image and story to be used for the purpose of Our Lady of the Lake’s Silent Heroes Wall as well as on LOPA’s website. Please click the checkbox to agree.

I hereby give consent for my hero’s name, image and story to be used for the purpose of Our Lady of the Lake’s Silent Heroes Wall as well as on LOPA’s website. Please note photographs and paragraphs may also be used for teaching and public relations purposes, published in institutional newsletters, and/or area newspapers, and/or may appear on local television stations.

LOPA Path of Remembrance *

We also invite you to join us at our Path of Remembrance events throughout the state. Your loved one will be honored at the event you choose, using all the information you provided in this form. Each event will include activities, butterfly release, light snacks and refreshments. Choose your location or select not attending.

Not attending

Saturday March 29 - Lafayette (Broussard) - St. Julien Park, 1pm-3pm

Sunday March 30 - Monroe (West Monroe) - Kiroli Park, 2pm-4pm

Saturday April 5 - Baton Rouge - Rural Life Museum, 11am-1pm

Sunday April 13 - Shreveport - American Rose Center, 1pm-3pm

Saturday April 26 - NOLA (Covington) - LOPA Donor Memorial Park, 10am-11am