2018 "Remembering those lost in Tennessee" Release
Thank you for taking the time to fill out this form. We, at Tennessee Overdose Prevention, are grateful that you are allowing us to use your loved one's photo as we can honor those we have lost. This form is only for those who were lost in Tennessee or who have family in Tennessee.  Contact us if you live in another state and will send links where you can post nationally or in that state.

In this form, we are asking for your permission to use a loved one's likeness in a photograph for any events, memorials, and promotional materials as we remember those affected by addiction and educate, implement, and develop resources for Tennessee Citizens regarding Tennessee's Naloxone and Good Samaritan Laws.

In addition, we also ask in this form if you are comfortable with us as we share these resources with friends in the recovery community. We trust these partners (and believe they will respect your stories), but we also prioritize your privacy and peace of mind.

If you have multiple family members you would like to include, please submit one form for each person. If your loved one' photo is already on the carousel on our website's homepage (tnoverdoseprevention.org), you do not need to submit this form.

You will know we have received your response when you see your loved one's photo in the "Remembering Carousel" on the homepage of our website, http://www.tnoverdoseprevention.org. You have to send the head shot photo through an email before it will be added to the carousel.

You will only receive an email if there was a problem with your submission, like if we don't receive a head shot, or if your photo has more than one person in it. Please do not resubmit the form thinking that we did not receive the first form that you filled out.


Sign in to Google to save your progress. Learn more
First Name of Person Submitting Release: *
Last Name of Person Submitting Release: *
Phone Number (XXX) XXX - XXXX: *
Email: *
City of Residence for the Person Submitting the Release:
State of Residence for the Person Submitting the Release
First Name of Loved One: *
Last Name of Loved One:
Age of Person in Photo/Video:
Relation to Person: *
Please give us a description of your loved one. What characteristics did your loved one have that you'd like them to be remembered for?
Date of Birth (MM/DD/YYYY)
Date of Death (MM/DD/YYYY)
City of Residence of Loved One:
State of Residence of Loved One
I hereby give my permission for Tennessee Overdose Prevention and its affiliates to use this photo or video for "In Memorial" presentations at events. *
I hereby give my permission for Tennessee Overdose Prevention and its affiliates to use this photo or video on the website: tnoverdoseprevention.org *
I hereby give my permission for Tennessee Overdose Prevention and its affiliates to use this photo for the Naloxone Advocacy Billboards. *
I hereby give my permission for Tennessee Overdose Prevention to read my loved one's name, age, and city/state at the International Overdose Awareness Day Event (s). *
At which event(s) would you like you loved ones name and information read? *
Which event will you be attending?
Clear selection
I have read and understand the permissions I have given to Tennessee Overdose Prevention. *
Signature: *
Date: *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms