Victim Submission

Please complete this form to register your loved one with Lost Voices of Fentanyl.

Your Information

Your First Name

Your Last Name

Your Email

Victim Information

Victim’s First Name

Victim’s Last Name

Victim’s DOB (MM/DD/YYYY)

Victim’s DOD (MM/DD/YYYY)

Forever Age

State / Province

Victim’s Photo (required)

Requirements: A clear, close-up photo of your loved one’s face. Any full‑body photos will be cropped to show only the face, head, and shoulders when possible. Do not submit photos where part of the head or face is cut off. Please do not submit photos with other people. No sunglasses, smoking, or drinking unless you have no other photos available. No graphics or added text — original photos only.

Acknowledgments

PHOTO ACKNOWLEDGMENT: By submitting your loved one’s photograph, you acknowledge that the image becomes the property of Lost Voices of Fentanyl, Inc., and you grant the organization permission to publish and use it in furtherance of its memorial, educational, and public‑awareness efforts regarding illicit fentanyl. You may revoke future use of the photograph in writing at any time; however, materials already published or distributed will not be withdrawn, altered, or removed

IMMEDIATE FAMILY ACKNOWLEDGMENT: I affirm that I am an immediate family member of the victim and that I possess the legal authority to submit their personal information and photograph to this nonprofit organization for its memorial and awareness efforts.

Relationship to Victim

Submitting your registration… thank you for your patience.