Office of Harm Reduction Remembrance and Recognition Form

Erie County Department of Health (ECDOH) Office of Harm Reduction

The opioid overdose epidemic has taken a heartbreaking toll on our community, claiming the lives of far too many. The opioid epidemic has given us all the more reason to celebrate and instill hope in individual accomplishments towards people’s treatment and recovery efforts.

If you would like to honor your loved one that has been taken by this opioid epidemic, or allow the ECDOH Office of Harm Reduction to support and recognize you in ongoing treatment and recovery efforts, please fill out the information below. You may also upload a photo of your loved one, or yourself, if you wish. By uploading a photo and content, you are granting permission to our department to include these photos and names in public displays.

If you have any questions, please call us at (716) 858-7695 or email Harm.reduction@erie.gov.

Your First Name

Your Last Name

Your Phone Number

I am submitting information for recognition of my own efforts in recovery.

Yes

I am submitting information in memory of a loved one whom I have lost.

Yes

Your Loved one's First Name

Your Loved one's Last Name

Your Loved One's Date of Passing (Optional)

Your Loved One's Date of Birth (Optional)

Would you like to upload a photo of your loved one to remember them or yourself for us to show support of your recovery?

Yes

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

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

Electronic signature and photo release agreement

I grant the Erie County Department of Health (ECDOH), its representatives, and employees the right to use my photo and/or name, or my loved one's name and/or this photograph of my loved one in connection with the above-identified subject. I authorize the ECDOH, its assigns, and transferees to copyright, use and publish the same in print and/or electronically. I agree that the ECDOH may use such photographs of my loved one, or myself, 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