Share Your Death with Dignity Story
Have you had an experience that inspired you to support or advocate for Death with Dignity, e.g. witnessing a horrific death of a loved one or current suffering of someone you know? Why do you support Death with Dignity?

We want to hear from you! You story will help us in our work promoting Death with Dignity laws around the U.S.

Thank you.

--Death with Dignity National Center
Sign in to Google to save your progress. Learn more
Your FIRST NAME *
Your LAST NAME *
Your STATE (two-letter abbreviation, e.g. OR for Oregon) *
Your 5-digit ZIP CODE *
Your EMAIL ADDRESS *
WHAT'S YOUR STORY? *
Please tell us your Death with Dignity story. Please keep in mind that we aren't looking for every single detail, just the most important ones. Be sure to describe why you support Death with Dignity.
Small Print *
By checking the box below you 1) grant Death with Dignity National Center (DDNC) permission to use your story in our communications; 2) certify that you have all the rights, power, and authority necessary to make the submission; 3) agree to not hold DDNC responsible or liable for any use of your story; 4) agree that any uses by DDNC of your story are made with no compensation to you; 5) certify that the language and contents of the story are not plagiarized from any other source and do not libel or slander any other party and that you assume full responsibility for any damages resulting from any claims to the contrary; and 6) understand that your email address will be added to our list to receive occasional updates.
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Death with Dignity National Center. Report Abuse
Google Forms