Reserve Your Amadora Legacy Video Spot

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 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 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 legacy@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 and option)

Please provide information about your diagnosis

How did you hear about Amadora Legacy Project?

Let us know how you heard about us.

Next Steps

After you submit your application, you will be directed to the event calendar to book your session. Please click the link that directs you to the next available dates.

Please let us know who is signing the 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.

Share Your Story Application

Applicant Information

Secondary Contact

Video Eligibility

How did you hear about Amadora Legacy Project?

Next Steps