Remembrance Wall Registration Form

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Virtual Remembrance Wall

Bereaved families are invited to share the names of their deceased loved ones who have passed away as a result of Dravet syndrome, for inclusion on DSF's Remembrance Wall. This virtual wall provides a place and a way for families, along with our community, to remember and honor their loved ones forever.

Beginning in 2021, each year June 15th will be recognized as Dravet Remembrance Day to allow us to remember all of those who we have lost to this disease.

You can register your loved one by completing the form below. Registered families will receive a mailed card for Remembrance Day.

Name of Deceased Individual*

Information of individual completing this form:

Email Address*

First Name*

Last Name*

Address, line 1

Country*

City

State

Zip Code

SUBMIT

Name
Address Line 1, Address Line 2
City, State Zip Code
Cell Phone
Contact Email