Day of Remembrance Registration Form

Your First Name

Your Last Name

Your Loved one's First Name

Your Loved one's Last Name

Your Phone Number

Your Loved One's Date of Birth (Optional)

Your Loved One's Date of Passing (Optional)

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

Yes

Please upload a photo of your loved one. File types accepted include gif, jpg, jpeg, png, pdf

One file only.
128 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf.

Electronic signature and photo release agreement

By checking this box, I acknowledge that:

I grant the Erie County Department of Health, its representatives and employees the right to use my loved one's name and/or this photograph of my loved one in connection with the above-identified subject. I authorize the Erie County Department of Health, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that the Erie County Department of Health may use such photographs of my loved one with or without their name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.

Would you like to be notified by email of the Erie County Opiate Task Force Meetings?

Yes

Your Email

Confirm Your Email