Apply for Amadora Legacy Video for Life Limiting Illness

Applicant Information

Applicant First name

Applicant Last name

Applicant Street Address

Applicant City

Applicant State

Applicant Zip Code

Applicant County

Applicant Phone

Enter in your 10 digit phone number without any periods, dashes or spaces.

Applicant Email

Applicant Preferred method of Communication

Cell

Email

Applicant Birthday

Month

Day

Year

Secondary Contact

Please provide information for a secondary contact, in the event you are unavailable.

Secondary Contact First Name

Secondary Contact Last Name

Secondary Contact Relationship to Applicant

Secondary Contact Phone

Enter in your 10 digit phone number without any periods, dashes or spaces.

Secondary Contact Email

Secondary Contact Preferred Method of Communication.

Cell

Email

Use Secondary Contact as Main Contact for Arranging Filming?

Yes

No

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

Gender

Race

Age

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 eligibility criteria

Diagnosis (please choose an option)

Please provide information about your diagnosis

Urgency

Please indicate the urgency of this application:

The video ideally needs to be filmed within 1 week of application.

The video can be filmed 7 days or more from the time of the application.

Filming Location

Please indicate the preferred location for your filming.

Applicant’s home (be sure to read the time requirement under Time of Day for Filming section below)

In hospice

In hospital

Time of Day for Filming

Each recording takes approximately one hour. Please note: our in-home videos require a 3-hour block of time for set-up, filming, and tear down of equipment. Morning filming sessions typically run from 8-11am and our afternoon filming sessions take place from 1-4pm. Please indicate your preference.

What is your preferred time of day

I prefer a morning filming session

I prefer an afternoon filming session

I am open to either morning or afternoon for filming

Are there any days of the week which will NOT work for filming?

How did you hear about Amadora Legacy Project?

Let us know how you heard about us.

Next Steps

Once your application is reviewed and your eligibility is verified, you will be contacted by our team to discuss the next steps in the process.

Let us know who is signing this application

I am the applicant filling out the form for myself.

I am filling out the form on behalf of the patient.

I confirm the Applicant/Patient is aware and agrees to be filmed

Legacy Your Way Application