MDFF Enrollment

Enroll with the Muscular Dystrophy Family Foundation – it’s quick, free, and easy! Join today to take advantage of programs offered by MDFF, which include financial assistance, adaptive equipment, family events, and more. Once you submit the below information, our staff will review and reach out within a couple weeks.

To qualify, ENROLEE MUST BE AN INDIANA RESIDENT living with a neuromuscular disease listed here. We are unable to support families living outside of Indiana at this time. If you have more than one person in the household with MD, you only need to enroll one.

Enrollee Information

Enrollee must be a RESIDENT OF INDIANA. The enrollee would be the person in your household living with MD or other qualified neuromuscular disease. Please be sure to fill out as completely as possible and double check for any typos.

Enrollee's Name(Required)

First Last

Enrollee's Address(Required)

Street Address Address Line 2 City State ZIP Code

Person with MD must live in Indiana

Enrollee's Email(Required)

If the enrollee is a minor or unable to receive emails, please input the primary guardian or caregiver’s email address to receive communications, invites, and resources.

Enrollee's Primary Phone(Required)

Enrollee's Birthdate(Required)

Enrollee's Gender(Required)

Enrollee's Primary Diagnosis(Required)

If you are uncertain of your diagnosis category, your doctor should have this information. If you do not see your diagnosis listed, please contact the MDFF office at info@mdff.org. The above list are qualified diagnoses that MDFF serves.

Does the enrollee have additional diagnoses? If so, you may enter it below.

Does the enrollee require use of any of the following?

Wheelchair

Walking device

Nurse/Health aide

Feeding tube

24hr supervision

Speech assistive device

None of the above

Hospital/Medical Facility for primary care

Family Information

Please enter family members living in the same household as the enrollee. The below family information is required for attending MDFF hosted events (zoo day, holiday party, etc).

Is the enrollee a…(Required)

Child (under 18) living with parents/guardians

Adult (over 18) living with parents/guardians

Adult (over 18) living with spouse

Adult (over 18) living on their own or with caregiver

How many siblings live in the same household?(Required)

Mother/Guardian 1 – Name(Required)

First Last

Father/Guardian 2 – Name(Required)

First Last

If there is not a second primary guardian, you may enter n/a

Spouse/SO of Enrollee(Required)

First Last

Please enter your spouse/partner/significant other’s name if living in the same household.

Do you have a regular or full-time caregiver/nurse/aide? (do not include immediate family members here)(Required)

Yes

Other

Sibling 1(Required)

First Last

Gender(Required)

Birthdate(Required)

Sibling 2(Required)

First Last

Gender(Required)

Birthdate(Required)

Sibling 3(Required)

First Last

Gender(Required)

Birthdate(Required)

Sibling 4(Required)

First Last

Gender(Required)

Birthdate(Required)

Sibling 5(Required)

First Last

Gender(Required)

Birthdate(Required)

Sibling 6(Required)

First Last

Gender(Required)

Birthdate(Required)

Sibling 7(Required)

First Last

Gender(Required)

Birthdate(Required)

Sibling 8(Required)

First Last

Gender(Required)

Birthdate(Required)

Sibling 9(Required)

First Last

Gender(Required)

Birthdate(Required)

Sibling 10(Required)

First Last

Gender(Required)

Birthdate(Required)

Is your family fostering other children in the enrollee's household?(Required)

Yes

Please enter the Full Names of children currently fostered in your home.(Required)

Number of your children/dependents living in Enrollee's household

Demographic Information

The following data is optional but requested solely for the purposes of reporting and grant and funding applications that will help provide more support & assistance to Hoosier families with MD. Grants often ask for demographic information such as income ranges, races, geographies, etc for the population MDFF serves. MDFF does not discriminate on the basis of any protected legal class when assessing applicant eligibility or otherwise providing charitable aid.

Enrollee's Race/Ethnicity

White/Caucasian/European

Black/African-American

Asian/Asian-American

Hispanic/Latino/Latina/Latinx

Pacific Islander/Native Hawaiian

Middle Eastern/North African

Native American/American Indian/Alaska Native/Indigenous

Multi-racial/Mutli-ethnic

Other

How many people have MD in this household (total) or other qualified neuromuscular disease? Include enrollee.

Name(s) of additional household members with MD

Annual Household Income

Main language(s) spoken in your household

English

Spanish

Mandarin

Korean

Arabic

Russian

French

German

Other

How did you hear about MDFF?

Facebook

Instagram

Other social media

Another family

Doctor/Hospital/Medical Facility

TV/News/Radio

Internet search

Other

Is your family currently participating in an Indiana waiver program?

Yes

Not sure

Enrollee's Employer, if applicable

Spouse's Employer, if applicable

Mother/Guardian1 Employer, if applicable

Father/Guardian2 Employer, if applicable

Liability Waiver(Required)

I accept & acknowledge

Liability Waiver, Agency, and Indemnification: By clicking the acceptance box, and in consideration for MDFF’s permission to attend certain MDFF events free or at a reduced charge, I hereby release MDFF and all of its agents, officers, servants, directors, employees, the donors, contributors, volunteers, and or participants from any liability whatsoever, in connection with the preparation, execution, fulfillment, or nonperformance at any and all outings both (1) on behalf of myself, personally, and (2) on behalf of any persons that accompany me to MDFF events, as a prior, authorized agent or legal custodian for those individuals. I declare and avow that, prior to accepting above, I have obtained the personal, fully-informed consent to accept this waiver as the agent of any and all individuals who will accompany me at any MDFF event. I declare that I will not allow any person to accompany me to, or direct any person to attend, an MDFF event, unless I know that person has effectively ratified this waiver either personally or by agent or custodian. If I allow any person to accompany me, or direct any person to attend an MDFF event, who has not ratified this waiver in an effective manner, I indemnify MDFF for any injury to that person that occurs at any MDFF event. The scope of the release and indemnity should be construed to cover all possible injury or nonrealization, and includes, but is not limited to: transportation; food; lodging; funding; entertainment; photography; advertising; emotional injury; and physical injury. I understand that I am not obligated to attend any MDFF events, whatsoever, and that MDFF will not discriminate against me in its provision of charitable services based on my attendance. I further understand that I am not obligated to allow any persons to accompany me to, or direct any person to attend, an MDFF event, and that MDFF will not discriminate against me in its provision of charitable services based on a failure to bring persons to, or direct persons to attend, any MDFF event.

Promotional Waiver(Required)

I accept & acknowledge

Promotional Materials and Social Media: MDFF hereby notifies you that, by participating in MDFF services or by clicking the acceptance box above, your identity, likeness, charitable aid, and medical information may be shared by MDFF for the limited purpose of promoting MDFF’s charitable works, aid, and services to the public. In order to further its mission, MDFF, through its agents, directors, officers, servants, or employees, periodically photographs, films, and/or electronically records MDFF events, interviews with participants, and the results of MDFF’s charitable aid. Those materials may be distributed to anyone, including the general public, magazines, radio stations, TV stations, newspapers, public presentations, social media, or other media outlets, or displayed on the MDFF website. MDFF also posts on social media about families who have received services/assistance and photographs related to services and outings, which may include information regarding the participant’s identity, likeness, charitable aid, and/or medical condition. I understand that by participating in MDFF services or by clicking the acceptance box above, I authorize MDFF to photograph, film, or electronically record me, as well as any persons for whom I act as custodian or agent, and distribute such materials as MDFF chooses. Accordingly, I understand that if I do not agree to these terms, I understand it is my responsibility to not participate in MDFF services.