First name
Last name
Your Phone Number
Person Being Honoured
Community / City
Province
Relationship to Person
Connection to Society (Years if known)
This submission is:
In honour of someone living with ALS
In memory of someone
Other
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Short memory or reflection (optional)
Is there anything you'd like people to remember about this person?
By submitting, I confirm I have permission to share this photo and information, and consent to the ALS Society NB&NS using it for the 40 Faces Wall, digital gallery, social media, marketing, campaign/event displays, and follow-up.
I have read and agree to the consent statement above.
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40 Faces Submission Form
