Terri's Legacy Project
Legal Professional Contact Sheet

Name  ___________________________________________________________

Address __________________________________________________________

City/State/Zip _____________________________________________________

Telephone numbers: office _____________________  cell _________________

Email address _______________________________________________

Specialty ________________________________________________________

States in which licensed to practice ______________________________________

Firm with which associated _____________________________________________

Willing to volunteer time consulting with families in life and death denial of treatment cases in local area? 
Yes      No       (Please circle one.)

Willing to consider representing patients and families seeking to obtain authorization for life-preserving medical treatment, food, or fluids on a pro bono basis, if expenses are covered?    
Yes      No       (Please circle one.)

Willing to consider representing patients and families seeking to obtain authorization for life-preserving medical treatment, food, or fluids on a paid basis?
Yes      No       (Please circle one.)

Able/ willing to travel within home state to assist families in these situations? 
Yes      No       (Please circle one.)

Please return completed forms to: Terri's Legacy Project, c/o Joleigh Little, 11228 S. Balsam Ave., Solon Springs, WI 54873 or email information to joleigh@centurytel.net.  This list will be maintained on an ongoing basis by the Terri Schindler Schiavo Foundation.