OK Let’s Create a Memory Mirror!

Memory Mirror Design Form

Name *

Email *

Add your email so you can save your mirror and complete at a later time if necessary

Address

Where shall we deliver to?

Phone

What number can we call if there is a difficulty finding your address?

I consent to memorymirror.ie collecting and storing my data from this form *

Yes I consent

What do you want to call this project? *

Select the background for your mirror *

Vibrant

Option 1

Stars in watercolour

Option 2

Water in watercolour

Option 3

Garland of flowers in watercolour

Option 4

Garland of blue flowers

Option 5

Green laurels

Option 6

Image Upload (jpg or png only)

Maximum upload size: 5MB

Who is in this photo? *

Write the text you want the recipient of the mirror to read under this image (e.g. my sister Jane, or my doctor John etc)

Notes

If there is more than one person in the photo you uploaded, you can write their position in the photo here

Where on your memory mirror should this photo appear? *

If the memory mirror was a clock, where would this photo appear on the face? e.g. 1pm for top right, 11pm for top left