Dr. Sheila Moore Tribute | Dream Day Foundation

Patient Name:(Required)

First Last

Date of Diagnosis:(Required)

Age at Diagnosis:(Required)

Please enter a number less than or equal to 130.

Diagnosis:(Required)

Current Treatment Status:(Required)

Current Patient Age:(Required)

Please enter a number less than or equal to 130.

Short summary of memories with Dr. Moore:

Photo Upload of patient & Dr. Moore

Drop files here or

Max. file size: 50 MB.

Date of photo(s), if known:

Photo Upload of patient during time of treatment with Dr. Moore

Drop files here or

Max. file size: 50 MB.

Date of photo(s), if known

If you would like to be a part of seeing this project completed, we ask you to consider making a donation. Costs associated with this project include artists time, technology and maintenance of the artistic piece, media outreach and interview production.

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Alternative options for supporting this project:

Provide your mailing address and we will send you a form and return envelope

Provide your contact information below and Dream Day Foundation will mail you full instructions along with an envelope for sending photos and your story.

Name

First Last

Address

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

Come in person to the Dream Day Foundation office so we can scan your photos and record your story. Please contact us by phone or email to confirm date and time of arrival to be sure someone will be available to meet with you.

Dream Day Foundation

1165 S Foster Drive

Baton Rouge, LA 70806

Mobile Phone: 225-572-4052

Email: info@dreamdayfoundation.org