Remembrance & Solidarity

This survey is for anyone living in the 417 area who has lost a loved one due to COVID-19, locally or elsewhere. We would like to remember your loved one.

Would you be willing to share some information about your loved one that we can include on a special COVID-19 Living Memorial page on Springfield-Greene County Health Department's website?

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* 1. You may share information about your Loved One here in this brief survey. However, we realize that some may prefer to talk about this sensitive matter through a phone call. If you would prefer a call, please indicate that and share your contact information with us so we can reach out to you by phone. To reach us by phone, you can contact our call center at 417-874-1211, option #2. 

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* 2. Name of Your Loved One (First/Last)

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* 3. Something Special about your Loved One

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* 4. Your Loved One's Occupation or Hobbies

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* 5. Loved One's Date of Birth

Date

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* 6. Loved One's Day of Passing

Date

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* 7. Obituary Link

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* 8. Photograph Release

I give permission for my Loved One's picture to be shared by a representative at the Springfield-Greene County Health Department. I give permission for the Springfield-Greene County Health Department to use my photographs on their website, in printed materials, brochures, and other formats as they deem necessary in order to promote public health and the Health Department’s services.

I understand that the Springfield-Greene County Health Department will not provide any financial compensation to me or to the person in the photograph.

If you agree, please indicate that below. 

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* 9. Would you like to include a photo of your Loved One?

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 10. Facebook Page Release

I give permission for my Loved One's information (including their photo) to be shared on the Springfield-417 COVID-19 Memorial Facebook page. I understand that this is not a Springfield-Greene County official Health Department Facebook site and that it is run by a community member.

If you agree to share your info on the Facebook page, please indicate that below.

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* 11. Your Contact Information

0 of 11 answered
 

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