1st Annual Sierra Donor Services
Locks of Legacy Memorial Ceremony

Join us for special guest speakers & placement of locks in honor of your loved one.

Thursday, November 12, 2020 at 3 PM

Due to social distancing, this will be a virtual event. An email will be sent with a link to watch the service online.

To reserve a lock, please complete the registration form below.

Locks must be reserved no later than August 28, 2020 to be included in the 2020 memorial ceremony.

Locks of Legacy Order Form

1. Your Contact Information

Your First Name

Your Last Name

Phone (optional)

2. Address

Address Line 1

Address Line 2

City

Country

State

Postal Code

3. Front of Lock:

Write your message for the front of the lock:
(You will have 3 rows of text, 15 characters per row including spaces)
Example:

Front of Lock:

4. Back of Lock:

Write your message for the back of the lock:
(You will have 2 rows of text, 15 characters per row including spaces)
Example:

Back of Lock:

5. Who is this lock in memory of? Please provide their full name along with date and location of donation (e.g., John Smith, January 2019, Sacramento, CA)

6. Would you like your loved one's name to be read out loud during the memorial ceremony?

YesNo, I would not.

If yes, how would you like their name to be read?
We will plan to say your loved one's name as represented below during the memorial service. Please type your loved one's name phonetically with punctuation so our speakers can say their name correctly.

7. Include a picture: Do you have a picture of your loved one you would like to include during the memorial ceremony? Click file upload to attach a photo. (Please note, everyone in attendance will see the picture.)

Media Release

I give permission to DCI Donor Services (DCIDS) to use any and all information I have provided, orally or in writing, including medical information, and any tangible items I have provided, including photographs and videos for the purpose of public and/or professional education about organ and tissue donation. I represent and warrant I am legally authorized to provide such information and items to DCIDS for educational purposes. I understand and agree the information and items I have provided DCIDS, or any part thereof, may be used in any public service medium that DCIDS may choose, including television, radio, website, social media outlets, newspapers, billboards, brochures and pamphlets. I understand upon release of this information, my identity or my loved one’s identity will no longer be confidential since DCIDS has no control over the information once it has been disclosed. I agree and understand I have no ownership and property rights in the information and/or items I have provided to DCIDS. I also understand I will receive no compensation or money for the use of the information and items provided; nor will I be charged anything. I further agree to indemnify and hold harmless DCIDS, its officers, agents and employees from any and all liability arising out of or related to DCIDS’s use of the information and items I have provided.

First Name

Last Name

Month

Day

Year

8. Would you like to be contacted for volunteer activities, hear about upcoming events, or receive the monthly newsletter via email? (If yes, check the boxes below and a team member will reach out via email)

I would like to hear about volunteer opportunities with Sierra Donor Services!I would like to hear about upcoming events!I would like to receive the monthly newsletter via email!

Thank you! By clicking "Submit" you will be sent to a confirmation page. A staff member will reach out to you directly if we have further questions.

- The Sierra Donor Services Team
916.567.1600

1st Annual Sierra Donor Services Locks of Legacy Memorial Ceremony

Thursday, November 12, 2020 at 3 PM

Locks of Legacy Order Form

3. Front of Lock:

1st Annual Sierra Donor Services
Locks of Legacy Memorial Ceremony