Section 1 of 1
ADAO Legacy Donation Page Form
Submitter's Email
Submitter's Email
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Submitter
Submitter
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I am the patient
I am a family member
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Submitter's First Name
Submitter's First Name
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Submitter's Last Name
Submitter's Last Name
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Submitter's Address
Submitter's Address
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Submitter's City
Submitter's City
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Submitter's State
Submitter's State
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Submitter's Zip
Submitter's Zip
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Submitter's Country
Submitter's Country
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Submitter's Phone
Submitter's Phone
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First Name for Donation Page
First Name for Donation Page
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Last Name for Donation Page
Last Name for Donation Page
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Submitting a photo is a requirement for your legacy page
Submitting a photo is a requirement for your legacy page
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Add file
View folder
Allow only specific file types
Maximum number of files
1
5
10
Maximum file size
1 MB
10 MB
100 MB
1 GB
10 GB
View folder
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Share a brief message about why you are building this legacy donation page. (300 word count maximum):
Share a brief message about why you are building this legacy donation page. (300 word count maximum):
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By submitting my story, I agree that ADAO may use
my story and photo in educational and advocacy materials.
ADAO will not sell, trade, or rent your personally identifiable information to third parties.
my story and photo in educational and advocacy materials.
ADAO will not sell, trade, or rent your personally identifiable information to third parties.
By submitting my story, I agree that ADAO may use
my story and photo in educational and advocacy materials.
ADAO will not sell, trade, or rent your personally identifiable information to third parties.
my story and photo in educational and advocacy materials.
ADAO will not sell, trade, or rent your personally identifiable information to third parties.
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I agree with the above story submission
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add "Other"
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