Family/Friend of a Patient Waiting for Transplant

Fill out the form below to submit your Story of Hope. If you would prefer, you can download this word document and email it to us at info@donatelifenw.org.

Your Information

First Name *

Last Name *

Email *

Gender

Birth Date *

Month

Day

Year

Country

Street Address *

City *

ZIP/Postal Code *

State/Province *

Phone Number

Transplant Information

Please tell us about your loved one's need for a transplant.

Organ(s), Eye(s) and/or Tissue(s) needed *

List the organ(s), eye(s), and/or tissue(s) your loved one hopes to receive.

Your relation to patient *

i.e. mother, father, child, sibling, friend, etc.

Your Story

The following questions are meant to help you focus on the most compelling parts of your story. From the information you provide, Donate Life Northwest will build a cohesive written piece that tells your Story of Hope. Please provide no more than 100 words per question.

Photo

Please upload a photo of you and your family if you wish.
Files must be less than 5 MB.
Allowed file types: gif jpg png.

Video link

Provide a URL weblink to a video if you have one

Describe your loved one’s life before they got sick.

Give a description in layman’s terms of what caused their need for a transplant.

Since being on the waiting list, choose a moment when they were sickest. What was their life like? Did they experience any physical/activity restrictions?

How long have they been waiting? How do you and your family feel waiting? How have your emotions changed throughout the wait?

Describe the effect that being on the waiting list has had on your family.

Describe what it means to you that people make the choice to be an organ/tissue donor. What would you like to say to them?

How will a transplant change your loved one’s life physically and mentally?

What is your advice to people who are unsure if they want to register as a donor?

After hearing your story, what message do you want people to walk away with?

Additional comments

Check ONE box that best describes your reason for submiting your story.

I'd like to share my story so it might be used to support Donate Life Northwest's mission.

I have attended a Volunteer Orientation, and I'd now like to join the Speakers Bureau.

Terms & Conditions

By submitting personal stories to Donate Life Northwest, individuals agree to the following statements:

Submission Statement 1

1) I agree that by submitting this personal story and photographs (optional), I authorize Donate Life Northwest to review submitted materials and determine use for publicizing transplantation, donation and to promote the need for organ, eye and tissue donors. Donate Life Northwest will notify me (using the contact information I have provided in this form) in the event that my story and/or images will be used.

Submission Statement 2

2) By clicking "Submit", I understand that my story may be used in the media (TV, newspapers, magazines, radio, etc); online (website, social media, etc.), and more generally as part of Donate Life Northwest’s outreach and promotional purposes.

Story Submission Agreement *

I agree to the submission terms.

Leave this field blank

Languages

Stories of Hope:

— Alysia Yamasaki

Family/Friend of a Patient Waiting for Transplant