Please be advised that when you submit this form, it will show a "Frontpage Error".  Please disregard this message as the form is working and the submissions are being received.  We are working to correct this problem. 

 

First Name 

Last Name (I either require your full last name or an initial for your last name.  If I receive submission without this information, your name cannot be added to the wall.)

Age

Today's Date (Names are placed in order of date submitted for wall.  If I receive a late confirmation, it will be placed in the next available space on the wall.)

I would also like you to include a personal quote, saying or message that means a lot to you. It could be your own message or you can feel free to use one of the examples listed below.

Check the box below that applies to you. If you are adding your own message, there is a message box to enter it below the example comments. Please try to keep personal messages to a minimum of 3 to 4 lines. If I receive longer messages, I may have to ask you to edit it so that it can fit on the space available for each name.

 

I will use an example comment I will use my own personal favorite

 

Never give up! Recovery is worth fighting for. Take that first step, it's worth it There is such a thing as recovery A survivor and proud of it!!! None of the above

Enter your own message, favorite quote or saying in the space provided below:

Please check box for the image that you wish to have displayed above your name.
Angel

Heart

Stained Glass

Flowers

Cross

Dove

Roses

Shooting Star

Butterfly

Faith

 

Before your name will get added to the Survivor's Wall, I will contact you to confirm the information you want displayed. Please fill out name and email address below so that I can contact you. If I cannot contact you to confirm, your name will not be added to the Wall. Email addresses are kept confidential. If you do not receive a confirmation letter from me within 6 to 8 weeks of submitting, please resubmit your message. You may have entered an incorrect email address or it might not have been received by me.  Due to limited space on the wall, only ONE submission per person will be allowed.  Once a name is placed on the wall, under NO circumstances will it be removed. Do not resubmit another message at a later time as you will not be added to the wall more than once. Also, the submission for the wall must be submitted by the person themselves.  I will not place names on the wall that are submitted by family members, friends, etc.  The Survivor's Wall is for the survivor's to place their own names and personal messages. 

Name     
E-mail