Request a Service – Wisconsin Nurses Honor Guard

Name of Family Member or Primary Contact Who Is Organizing the Service *

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Last

Those requesting the service need to be either a family member, clergy, funeral director, or other individual directly involved with the funeral planning of the fallen nurse.

Primary Contact Person's Email *

Primary Contact Person's Phone Number *

Requestor: What is your relationship to the nurse honoree? *

Name of Nurse We Are Being Asked to Honor *

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Last

All information from here to the bottom of the form pertains to the nurse that we are being asked to honor. Please provide the appropriate answer (if known) with the honoree's details. Thank you.

What is/was the highest level of nuring practiced by the honoree? *

LPN
RN
APRN
DNP/PhD

Date and Time of Memorial / Funeral Service *

Expected Honor Guard tribute time? *

What time do you anticipate our 10 minute Honor Guard tribute performed? Please note that we arrive 30 minutes before and depart immediately after the tribute and therefore require specific scheduling in order to meet these times. Ideal timing is the transition period between visitation to funeral service.

Name and Phone # of Funeral Home Contact *

Location of Service (Address) *

How would you describe the nurse and the care that they provided? *

We understand that talking about these things over the phone can be hard during this difficult time and writing them here may be easier. These details will help us to add a more personalized touch to our service. Consider telling us things like: ~types of specialties worked (ICU, ER, Peds, etc)? ~how many years worked? ~where they went to school, what degrees they held, when did they graduate? ~did they have a special passion for something? ~what were they known for? ~or any memorable, funny, loving, touching story? ....these are all just ideas, please do not stress about specifics if you do not know the details. Just tell us what you know from your heart and memory.

Our service concludes with presentation of one (1) single lamp. Who will be the individual receiving this lamp? (Name and relationship to the nurse) *

After tribute completion, does WNHG have permission to post a photo and tribute of the honoree to the WNHG Facebook Page and Website ? *

If the answer is yes, please email us the image that you prefer us to use, otherwise we will use the image found on the online obituary.

Acknowledgement *

Please Note! When requesting an Honor Guard service, you understand that we are volunteers. Attendance of WNHG members at any service is based on member availability and our presence is therefore not guaranteed. Please type "I agree" if you agree and understand this.

Name