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 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)

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

Please provide information on your diagnosis and severity and any other information deemed appropriate

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.

Applicant birthdate

Healthcare provider

Clinic Name

Office phone

I consent to allow Amadora Legacy Project to contact my healthcare provider to obtain necessary health related information, as it applies to my application for the Legacy video.

Video preferences

How did you hear about My Amadora Legacy Program

Next steps

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

Your Signature

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