People Who Inspire Us Submission Form

"The People Who Inspire Us" Submission Form

Fill out the form below to have your story featured on the Pacific Northwest Transplant Bank webpage.
The personal story about your experiences with the donation process can inspire and teach others how lives can be forever changed by organ donation, and how special the gift of organ donation is. Thank you for taking the time to share your story for our webpage.

We will contact you once the story is published on the webpage. Please email Rebecca Simon at simonr@ohsu.edu, or call 503-494-5560 if you have any questions or concerns.
Your Information

* = Required Field
Your Name*

First NameLast Name
E-mail
Phone Number*

Area CodePhone Number
Preferred Method of Contact (Select all that apply)

PhoneEmail
Your Loved One's Information
Your Loved One's Name*

First NameLast Name
Please upload a photo of your loved one.

Browse Files
If the file is too large, email it as an attachement to olseno@ohsu.edu Cancelof
About Your Loved One
Please write about your loved one in the box below. If you are having trouble, and need inspiration, visit our webpage to read what other families have included in their own stories (http://pntb.org/who-we-serve/the-people-who-inspire-us).

You are welcome, though not required, to include dates you feel are important, ages, organs donated, your experiences communicating with recipients. Please share whatever information you are comfortable being viewed by the public.
Enter Your Text Here (please do not exceed 500 words):*
By checking this box, I hereby consent to the use of my loved one’s name and likeness for the sole purpose of promoting organ and tissue donation. I understand that the use of his or her name and likeness may include, but not be limited to, photographs, newspaper articles, brochures, displays, television, radio, or any other public community relations material. I hereby acknowledge that this authorization is volunteered without obligation of any kind on the part of Pacific Northwest Transplant Bank or its designated agents.*

Yes, I Consent
Should be Empty:

"The People Who Inspire Us" Submission Form

Your Information

Your Loved One's Information

About Your Loved One