Wall of Fame Request Form
Please provide us with the information to add your child to our Wall of Fame.

Please allow 5 business days for your information to be updated on the Wall of Fame web page. If you do not see your child within 5 business days of submitting your information, please contact us at hope@huntershope.org.

Also, please make sure that you have registered as an affected family with Hunter's Hope. If you have not yet registered, please do so here: https://goo.gl/YLgBx1

Thank you!

Affected Child's First Name *
Your answer
Affected Child's Last Name *
Your answer
Affected Child's Birthdate *
Your answer
Affected Child's Heaven Date (if applicable)
Your answer
Affected Child's City *
Your answer
Affected Child's State *
Your answer
Leukodystrophy *
Your answer
Name of person filling out form *
Your answer
Relationship to Child *
If you answered "Other" to the question above, please describe.
Your answer
Email address *
Your answer
Phone number *
Your answer
Please email a close-up picture of your child's face to hope@huntershope.org. Please include your child's first and last name with the photo with the subject line "Wall of Fame".
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