Thank you for your interest in participating in MADD's Online Victims Tribute. This project seeks to give a voice to the victims of drunk and drugged driving, as well as their loved ones - to acknowledge the reality of their losses and to bring that reality to a society numbed by statistics.

DIRECTIONS
The form below can be used to submit the information about your tribute to MADD online; however, to protect both MADD and victims, we cannot post your tribute to MADD's Web site without a signed release. You may also wish to compose your tribute message off-line using a word processor or text editor; that text can then simply be cut-and-pasted into this form once you are ready.

After submitting your tribute you will be taken to a page where you can print out a customized release that will already include all your information. Then simply sign the printed release, attach a photograph and mail it to MADD (all instructions are on the release form you print out)

If you do not have a printer, instructions will be included how you can request that the release form be sent to you through the mail.

Return to MADD.org

SUBMISSION FORM

Victim's First Name:
Victim's Middle Name:
Victim's Last Name:
Victim's Home City:
Victim's Home State:
State of Crash:
Age at time of crash:
Crash Anniversary:	(please format '01/01/2001')
Victim Injured or Killed:	Injured Fatality
Gender:	Male Female
Ethnicity:
(Ethnicity information is solely for internal MADD purposes, and will not be included in the on-line tribute.)
Tribute submitted by (your name):
Your relationship to victim: (injured victims may indicate 'Self')

Please provide us with information on how we can contact you if there are questions regarding your tribute submission. MADD respects your privacy: this information will not be shared with anyone and you will only be contacted by MADD if we have a question about your tribute.

Your address:

Your city:
Your state:
Your country:
Your zip code:
Your email address:
Your phone number:

Please include your tribute message below (approximately 100 words). For legal reasons, if you choose to include information about a crash, please limit it to factual, verifiable information.
Victim's Picture:
Disclaimer:	By clicking the submit button you are giving MADD permission to post your tribute on it's website.