The Wall Las Memorias AIDS Monument Name Submission Form
The Wall Las Memorias (TWLM) is dedicated to promoting wellness and preventing illness among communities of color affected by HIV/AIDS by using the inspiration of The Wall Las Memorias AIDS Monument as a catalyst for social change. We invite community members at large to submit the names of loved one's lost to AIDS or HIV complications. New names will be engraved onto the name panels on the monument and revealed during a special re-dedication ceremony to mark the unveiling of the renovated site. The names submission process is currently free of cost and open to community members from throughout the country. We also invite you to submit photos and videos of your loved one's along with your names submission form for a future virtual project.
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Applicant Name (First, Last) *
Address of Applicant (Street Address, City, State, Zip) *
Telephone Number *
E-Mail Address *
Name of Person (Deceased) to be Memorialized (as it will appear on the AIDS monument wall panel) *
Deceased's Relationship to the Applicant
I have reviewed the above information and verify that the statements made are true and correct. I attest to the fact that the decease died as a result from complications of AIDS (Acquired Immune Deficiency Syndrome). All information on this form is public and will be used only for the purposes of The Wall Las Memorias AIDS Monument and The Wall Las Memorias non-profit organization 501(c)3. *
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