Threads of Love Memorial Quilt Release Form

Please complete this form when are you are ready to mail in your quilt square.*

Yes, I have mailed in my quilt square.
No, I have not yet mailed in my quilt square.

Squares should be mailed to: Gift of Life Donor Program Attn: Family Support Services 401 N. 3rd Street Philadelphia, PA 19123

Donor's Name*

Relationship*

The donor is my

Spouse
Parent
Child
Sibling
Other (please share below)

Relationship*

The donor is my:

Name of individual submitting quilt square*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

In case we have any questions and need to reach you.

Email*

Enter Email Confirm Email

In case we have any questions and need to reach you.

Donor Tribute (optional)

If you would like to submit a written tribute (300 words or less), please submit it via this form. You can also submit the tribute at a later date by sending it to family2@donors1.org.

Authorization and Release*

I agree to the authorization and release.

By completing this submission, I authorize Gift of Life Donor Program and its affiliates to use, disclose and publish any biographical information, profile and/or images I’ve submitted to Gift of Life in connection with my quilt square including, without limitation, the tribute for the purposes of education, research and promoting the issues of donation and transplantation. I understand this may include, without limitation, images in publications, websites and/or audio-visual presentations. I hereby release Gift of Life Donor Program and its affiliates of all rights I may have in connection with such use.