Moment of Silence

The virtual Moment of Silence is a unique way to honor and remember your loved one as a Donor Hero.  We invite you to share a tribute and photo(s), as you are ready and comfortable.  
Please complete the information below to submit your request to our team.

Virtual Moment of Silence
Donor Hero's Name
Donor Hero's Name
First
Last
Your Name
Your Name
First
Last
Are you an employee of Indiana Donor Network filling out this form on behalf of the donor family?
Indiana Donor Network employee name
Indiana Donor Network employee name
First
Last
I would like to honor my donor hero through a Virtual Moment of Silence that will be shared on the Indiana Donor Network social media accounts.

Maximum file size: 3MB

Limit 4 files.
Please indicate when you would prefer the post to be shared.
MM/DD/YYYY
MM/DD/YYYY
Media Release

I grant Indiana Donor Network, Donate Life Indiana and/or any subsidiaries, affiliates or partners of either (collectively, “Indiana Donor Network”) permission, without further compensation, to use my name, likeness, information, images, voice and/or recordings of me for education, public relations or any other purposes deemed appropriate by Indiana Donor Network. If indicated below, I am granting this same permission with respect to anyone included in the story to my connection to donation and/or transplantation for whom I am a parent, legal guardian or legal next of kin as applicable.

I agree to hold Indiana Donor Network and its successors, directors, officers, employees, sponsors, representatives or agents harmless for any and all claims, losses or actions resulting from the use of my or my loved one’s name(s), likeness, information, image(s), voice and/or recordings.

Your Name
Your Name
First
Last
Address
Address
City
State/Province
Zip/Postal
If signing for deceased donor and/or an individual under the age of 18: I certify that I am the parent, legal guardian or next of kin of the individual named above and I give my consent without reservation or compensation to the foregoing on this individual’s behalf.