The Max Foundation

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Memorial Wall Registration

If you prefer to send the information via email, please email your memorial story to thewall@themaxfoundation.org.

Or, you can mail the information to:

The Max Foundation
c/o The Wall
110 W. Dayton, Suite 205
Edmonds, WA. 98020

When you are done completing the form below, please choose submit. (* indicates required fields)
Memorial Name:*
Date of Birth:
Date of Passing:
Diagnosis:
If Other Cancer, please specify:
Have you or your loved one received services from The Max Foundation in the past?:	YesNo
Web Page URL:
A default tribute will be posted in memory of your loved one. If you would like to post your own personal tribute please re-type the text in the box on the right. Limit of 1500 characters:	You are gone, but your memory will live on in our hearts and minds forever. We post this tribute to you to honor your life and the joy you brought to us. We miss you and will treasure your memory always.
Add a picture or select one from below. Must be in JPEG or GIF Format:

Senders Name:
Email Address:*
Country:*

Your privacy is important to us. Please read The Max Foundation privacy policy or Terms of use for the Memorial Wall before submitting.
Please check your information and then choose Submit Application

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