Any One of Us Portrait Request Form

Please fill out this form if you would like a request a portrait of your lost-loved one to police brutality to support our mission of spreading awareness to this cause. Our portraits are 8x10 inches on canvas and are created with care. Please understand that the portraits take time to make. You will recieve an email when the portrait is done and shipped out.

What's your name?

Phone number

What's your relationship to them?

What's your loved one's name?

How old were they?

Are you authorized by a family member or legal parent/guardian to submit a photo of them?

Yes

Please upload a photo

Tell us their story

Would you like their name and story to be shared on our online gallery?

Yes

No, only the portrait displayed on the gallery

No, nothing displayed on the gallery

Please enter the full address of where you want the portrait to be sent

Please select "I agree" as a legal signature agreeing to the following terms.

I agree

I, a family member of the deceased named above or an authorized designee, authorize and release the likeness of this person to be rendered in portrait form by an artist from Any One of Us. I understand that this original portrait will be received in the mail for my personal use. I understand that no commercial profit will be made from the portrait or its use.

Please select "I agree" as a legal signature agreeing to the following terms.

I agree

I do not agree

I agree that Any One of Us may use a print or image of the original artwork for public display on the internet, to complete our mission to spread awareness of systematic police brutality in America.

**If you do not agree to this, a portrait will still be created and sent to you, but it will not be displayed on the internet

Do you have any comments or questions (optional)?