Memorial Honor Roll Form

In the event of an Ontario Police Member’s death because of the line of duty, any police member or the family of the deceased can complete and submit the online Honour Roll submission form to the OPSM. During such a heavy time of grief, if you need any support filling out the submission form, please email: memorial@canadabeyondtheblue.com

Guidelines for Submission:

The police member being submitted was an active Ontario Police member during the time of death
The police member being submitted died by suicide as a direct result of a trauma or injury sustained while performing their job

Post Submission Process: Once the form is received, the OPSM will review the submission to ensure that the guidelines have been met and determine whether the police member will be included in the memorial. The OPSM understands that cumulative exposure to on-the-job trauma can significantly impact the mental health of police members and as such, is dedicated to understanding the complexities around mental health. If there is any additional information required, the OPSM will articulate their rationale to the applicant via email. The OPSM is responsible for maintaining the dignity of all submissions and will keep this core value at the forefront during the process.

Historical Names: The OPSM includes the names on the Honour Roll only if they are put forth through the online submission process. If a name does not appear, please connect with us and the family of the deceased so that together we can ensure those who served, will never be forgotten.

Deceased Member Information

Member’s Full Name:

First Last

Member’s Police Service of Hire:

Member’s Badge or ID Number:

Member’s Rank/Title:

Member’s Date of Hire:

Member’s Date of Birth:

Member’s Date of Death:

Member’s Work Location at Date of Death:

Exact Name to be recorded on the Memorial:

Please confirm the following:

The police member being submitted was an active Ontario Police member during the time of death

The police member being submitted died by suicide as a direct result of a trauma or injury sustained while performing their job

APPLICANT INFORMATION

Name of Applicant:

First Last

Applicant Relation to Member:

Applicant Mailing Address:

Applicant Phone Number:

Applicant E-mail:

If you are not the family of the deceased, have you connected with the family and are they aware of and agree to the submission

Name of Contacted Family Member

First Last

Phone of Contacted Family Member

Email of Contacted Family Member

Explain why you have not contacted family.

If you would like the police member to be commemorated on the OPSM social media pages on their specific memorial anniversary day, please upload a photo (preferably a headshot) of the deceased.

Max. file size: 2 GB.

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Memorial Honor Roll Form

Deceased Member Information

APPLICANT INFORMATION

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