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Legacy Video Application

Eligibility requirements for this service are defined as: participants local to central 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

Please provide an alternate contact

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

Video Eligibility Verification

Eligibility for this service is defined as: diagnosis of a life-limiting illness that will limit the natural life span of the participant (stage IV cancer, ALS, Huntington’s, Alzheimers, Parkinsons, etc)

In order to proceed with a Legacy video, your healthcare provider will need to verify that you meet the eligibility criteria. Please provide your healthcare provider’s name and contact information.

Video preferences
Next steps

Once your eligibility is verified, a dedicated Legacy Coach will connect with you to discuss your video in more detail. 

Thank you for filling out the legacy application. We will begin the review process and reconnect with you to schedule your video recording.

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