Legacy Page Submission Form
Share Their Story
Please share the name and story of the individual you would like to memorialize in a legacy page. The National Aphasia Association will use these responses to create a legacy page in this person's honor.
What is the full name of the individual who will be memorialized in this legacy page? *
What is this person's connection to the aphasia community (i.e. caregiver, person with aphasia, professional)? *
What day was this person born (month, day, and year)?
When did this individual die (month, day, and year)? *
Please share a short passage about this person, including how they were impacted by aphasia. *
Please share a high-resolution image of the person being memorialized.
Either upload the image below, or email the file to naa@aphasia.org with your name and the name of the individual in the photo.

Photograph Consent and Release:
Through my submission, I authorize an employee or agent of the National Aphasia Association to publish and display the attached photograph or photographs on www.aphasia.org or social media accounts controlled by the National Aphasia Association. I also agree that the National Aphasia Association may identify the individual or individuals in the attached photographs by name.

Image upload:
Contact Information
Please share your own information below so that, if necessary, we may contact you with questions about this page.
What is your name? *
What is your email address? *
What is your relationship to this individual? *
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