Legacy Video Application

Eligibility requirements for this service are defined as: participants local to Iowa who have been diagnosed with a life-limiting illness that will limit their natural lifespan. At this time, eligibility includes those with Huntington’s, ALS, Alzheimer’s, stage IV cancer, Parkinson’s, or those actively enrolled in a Hospice program. If you have questions about whether you meet eligibility requirements, please contact us for clarification.

This opportunity costs you nothing, but will mean everything. You tell your story. We'll do the rest.

Applicant Information

Applicant Name

Legal guardian/patient advocate (if under age 18)

Applicant Email Address

Applicant phone number

Applicant Street Address

Street Address Line 2

City

State

Zip code

County

Please provide an alternate contact

Alternate contact name

Relationship

Alternate Contact Email

Alternate contact phone

Use this alternate contact for primary communication

The following questions help us to identify possible grant funding in which demographics play a key role.

Video Eligibility

Eligibility is defined as: diagnosis of a life-limiting illness that will limit the natural life span of the participant. If you have questions about eligibility for an illness not specified below, please email us at info@amadoralegacyproject.org and we would be happy to answer any questions for you.

I verify that I have been diagnosed with an illness that meets the eligibility criteria

View terms of use

Please provide information about your diagnosis

Video preferences

How did you hear about the Amadora Legacy Project

Next steps

Once you submit this application, a dedicated Legacy Coach will connect with you to discuss your video in more detail.

Your Signature

Thank you for your submission.