Sample Honoree Form

NEMSMBR participants memorialize these Honorees during the Routes by:

Reading the names of the Honorees each day at memorial services;
Carrying dog tags and biographical information of the Honoree throughout the events, either while cycling or performing various logistical support roles;
Sharing dog tags with family -- or colleagues -- of the Honoree during the Route, or upon conclusion of the event;
Sharing with one another the unique qualities and details of each Honoree's accomplishments and sacrifices to the profession; and
Displaying biographical information publicly in a "traveling temporary monument" in cities across the country.

Submission for 2023 Routes are open. To request that a person is honored in our 2023 events, please complete the form below by March 31, 2023.

Honoree's Information

Name of Honoree*

First Last

Hidden

First and Last Name of Honoree

Pronunciation Assistance (optional)

example: ROO-bee (Ruby) or VAY-duh (Veda)

Date of Birth*

City of Residence*

State of Residence*

EMS Cerification(s)*

Examples: EMT, Paramedic, First Responder, Dispatcher, Flight Paramedic, Flight Nurse, etc

EMT

Paramedic

First Responder

Dispatcher

Flight Paramedic

Flight Nurse

Other

EMS Agency / Department / Affiliation*

Date of Death*

Cause of Death*

Do you plan to submit this individual to the National EMS Memorial Service?*

Link for more information: National EMS Memorial Service

Yes

Unsure

Upload a photo*

Please use the name of the honoree in the file name.

Accepted file types: jpg, jpeg, png, gif, Max. file size: 50 MB.

Brief Biography and Accomplishments*

(i.e. hobbies, surviving family, awards they’ve received)

Obituary*

Provide a website link to an obituary.

Submitter's Information

Submitter's Name*

First Last

Submitter's Email*

Enter Email Confirm Email

Submitter's Phone*

Relation to Honoree*

Family

Friend

EMS Agency / Department Contact

Learned of the situation from News or LODD announcement

Intend to Ride in honor of this person in 2023 Routes

Condolence Card Request (optional)

to family and/or friends

to EMS Service/Agency/Department members

The National EMS Memorial Bike Ride would like to send notes of condolences whenever possible to surviving family members and colleagues. This will serve to remind the family members of the mission of the Ride, and of our interest in honoring their loved one.

Condolence Cards Complete Address (separate each entry)