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2. By completing and signing this form you confirm, that you have read and agreed to the Roadside Memorial Marker Program Policy Statement below
   • Any person that has died as a result of a motor vehicle, pedestrian, or bicycle crash on segments of roadways under the jurisdiction of the City of Cocoa is eligible to have a memorial sign erected in his or her honor.
4. • Requests for a memorial marker shall be submitted in writing to the Public Works Streets Division by completing and e-mailing this Memorial Marker Request Application to PublicWorks@cocoafl.org. Requests may be made by immediate family members or friends. All forms must be signed by a family member. If a friend is submitting the request on behalf of a family, a signed letter is to be provided by the immediate family to authorize the submission of this application.
6. • Memorial markers will be allowed to remain in place for one year after installation unless earlier removal is necessitated by construction activities.
8. • Memorial markers will be designed, constructed and installed by the Public Works Streets Division. The Streets Division will be responsible for designing the sign and ensuring proper and safe placement – the exact location will be at the discretion of the City. Incident location will be verified by City Staff prior to the approval of this application and placement of the sign. Memorial markers will not be allowed within the limits of active construction work zones.
10. Location of crash:
11. Date of crash:
    Date of crash:
13. Name of deceased:
15. Safety message requested on sign:

    1. Buckle Up
    2. Don't Text & Drive
    3. Drive Safely

    1. Speeding Kills
    2. Don't Drink & Drive

    1. Watch the Road
    2. Stay Alert
17. Name of person requesting sign:
18. Relationship to deceased:

    1. Family member
    2. Friend
20. Address1
22. Address2
24. City
25. State
26. Zip
28. Daytime Phone Number:
29. Evening Phone Number
31. Email address:
33. I have read and agree to the Roadside Memorial Marker Program Policy Statement
35. Signature of person requesting sign*
    By typing my name in this form, I affirm the accuracy of information provided on this application. I understand that this constitutes a legal signature and confirms that I agree to the above terms.
36. Date
38. Requests may be made by immediate family members or friends. Please note, requests from friends require written approval from the deceased’s immediate family.
40. Family member name:
41. Relationship to deceased:
43. Immediate family member authorization signature*
    By typing my name in this form, I affirm the accuracy of information provided on this application. I understand that this constitutes a legal signature and confirms that I agree to the above terms.
44. Date
48. City of Cocoa Roadside Memorial Marker Program Policy Statement
50. Purpose: The purpose of this policy is to establish the guidelines for the placement of standardized roadside memorials for people that have died as a result of a motor vehicle, pedestrian or bicycle crash on roadways under the jurisdiction of the City of Cocoa.
52. Authority: The City of Cocoa Public Works Street Division is responsible for the implementation of the Roadside Memorial Marker Program.
54. Effective Date: This policy will be effective upon the formal adoption by the City of Cocoa City Council.
56. Scope: The installation of a roadside memorial marker will be processed in accordance with the following:
58. 1. Requests for a memorial marker shall be submitted to the Public Works Streets Division by filling out a Memorial Marker Request Form. The form will be available online from the City’s website or by calling the City. Requests may be made by immediate family members or friends. Please note, requests from friends require written approval from the deceased’s immediate family.
60. 2. Installation Memorial markers will be designed, constructed and installed by the Cocoa Public Works Streets Division. The Streets Division will be responsible for designing the sign and ensuring proper and safe placement – the exact location will be at the discretion of the City. Memorial markers will not be allowed within the limits of active construction work zones. There shall be no activities while the memorial marker is in place that pose a safety hazard to the public or that violates any provision of Chapter 316 of the Florida Statutes concerning stopping, standing, parking, or obstruction of traffic on public roads. Memorial Markers will only be installed on roadways under the jurisdiction of the City of Cocoa residential areas where fatalities occurred with the written permission of the property owner whose property is abutting the right of way where the memorial is to be placed. The applicant is to provide this permission or approval from the property owner abutting the right of way with this application. The applicant will be notified once the installation is complete.
62. 3. Time Period Memorial markers will be allowed to remain in place for one year after installation unless earlier removal is necessitated by construction activities. After one year the sign will be removed by City forces.
64. 4. Sign Design The memorial marker shall be a 15” diameter aluminum sign with a white background and black letters. The sign message will state “Selected Safety Message From Application – In loving memory of [First and last name]”, and the family will have the option of adding the deceased’s name to the sign. The sign will be mounted at a height of 3.5’ (42”) from the ground to the top of the sign.
66. 5. Cost The City will incur the cost of design, construction, installation, maintenance, and removal of the memorial marker. The City will retain ownership of the sign upon removal.
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68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

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