FED UP! Coalition · FED UP! Coalition Member Registration

Name

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First Name

Last Name

Organization/Employer

Contact Information

Address Line 1

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Address Line 2

Country

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State or Territory

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Zip Code

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Province or Territory

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Email

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Verify Email

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Would you like to have your lost loved one honored on social media?

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Yes

No

About Loved One

Write a short paragraph about your lost loved one to be posted on social media and our website, we will honor your loved one by posting their photo and your words describing how they were special to you on our website, facebook and twitter.

What is the web URL of your Facebook profile?

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Amount

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$10 - Fed Up Member Monthly

$100 - FED UP! Membership Annually

$

Donation Schedule

If you would like to provide additional support to the FED UP! Coalition, please note the opportunity at the end of this sign-up process to make an additional donation. Thank you very much!

Would you like your membership to memorialize or honor a loved one?

Yes

No

Please Select the type of tribute

In Memory Of

In Honor Of

Please provide the name of your lost loved one

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Prefix

First Name

Last Name

Suffix

Middle name or initial

Please provide the name of the person you're honoring

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Prefix

First Name

Last Name

Suffix

Middle name or initial

Please add his or her date of birth

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(mm/dd/yyyy)

Please add his or her date of death

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(mm/dd/yyyy)

Would you like the name of your lost loved one to be added to our website and communications?

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Would you like the name of the honoree to be listed on our website and communications?

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Would you like your lost loved one to be added to our 'Lost Loved One's' memorial video and other communications?

You may view an example of our current ‘Lost Loved Ones’ memorial video at the following link. https://youtu.be/tu9JpvatJrU

Please add a photo of your lost loved one

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We recommend using a high-resolution photo (1920 x 1080 pixels).

May we notify the person this gift is honoring?

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Please provide the person's email

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Verify Email

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Email Acknowledgement

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The FED UP! Coalition communicates with our members via email. By becoming a member, you acknowledge that the FED UP! Coalition may send you e-mail updates and relevant news. You may unsubscribe from our e-mail list at any time without affecting your membership status. We respect your privacy and will never share your e-mail with organizations without your consent. If unsubscribed, you will continue to receive transactional e-mails such as confirmation messages and receipts.

I understand

Join the FED UP! Coalition

FED UP! Coalition Member Registration

Contact Information