Submit to the Virtual Donor Memorial

IIAM invites all research donor families to contribute to the Virtual Donor Memorial. This Memorial is dedicated to the memory of your loved one’s donation to medical research.

There is no deadline and you and your family can contribute at any time. Below are some instructions and guidelines for how you can participate in the Memorial. Also below is a release form that allows IIAM to display the item submitted by your family on our website. Please complete and sign the release form and return with your loved one’s photo or memento.

Instructions:

  • Submit a photograph, or a memento that can be photographed, of your loved one; we would prefer a copy rather than an original. Original photographs may not be returned.
  • Electronic/digital photos are also accepted via e-mail. These can be sent to IIAM Family Aftercare
  • We invite you to share information about your loved one that can be included on our website. This can be a short poem or story and be no more than 100 words in length.
  • We ask that only one photo per donor family be submitted.
  • Within 4 weeks we will send you and your family a letter confirming receipt of the photo.
  • To view your loved one’s tribute or to see samples of other family’s tributes, please visit the Virtual Donor Memorial. Click on the photo to read the donor’s tribute/memorial.

Submitting to the Memorial

Please complete and sign the release form and return to IIAM Family Aftercare:

IIAM Olyphant Office
ATTN:
IIAM Family Aftercare
1175 Mid Valley Drive,
Olyphant, PA 18447

Other release form submission options:

  • You may also fill out the online form below.
  • Or fax your completed form to 570-496-3423 and email your scanned photos to IIAM Family Aftercare.
  • Or scan it and email it along with the scanned photos to IIAM Family Aftercare.

AUTHORIZATION FOR RELEASE

I hereby donate the materials listed below (the “Donated Materials”) to the International Institute for Advancement of Medicine. This donation is made as a contribution to the IIAM Virtual Donor Memorial. I am aware that the Virtual Donor Memorial will be constructed for public display and be available on the web, in recognition of all research donors and their loved ones.  I also fully release the materials without expectation of return.

Your Name*
Address
Email*
Phone
Donated Materials*
In Memory of*
Relationship to Donor*
His/Her Date of Birth*
Date of Death*
I hereby authorize IIAM, its affiliates, agents and independent contractors to use the Donated Materials and understand that I have waived any right that I, my estate or any heirs or assigns may have to any fee or royalty as a result of this use.
Please return the Donated Materials to me at the following address: (IIAM will not return the Donated Materials unless indicated in this space.)
I further understand that IIAM shall use its best efforts to display them as part of the Virtual Donor Memorial and that IIAM shall have the right to modify or change the Virtual Donor Memorial at any time. I also release IIAM, its affiliates and their agents, independent contractors, officers and employees from any liability connected with the exhibition of the Donated Materials or the failure to return the Donated Materials to me in their original condition.
Witness*

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