The River & The Rock Award 

Are you a resident of Indiana? 

If you are not a resident of Indiana, please do not complete a form. Our organization is currently only able to serve residents of Indiana.

YesPlease enter the Are you a resident of Indiana?.

Name of person completing request (first, last)  Please enter the Name of person completing request (first, last).

Relationship to person with MD (select from dropdown) 

Self Parent/ Guardian Sibling Doctor Medical Professional (case manager, nurse, social worker, etc.) Other

Please enter the Relationship to person with MD (select from dropdown).

Name of person with MD (first, last)  Please enter the Name of person with MD (first, last).

Neuromuscular Disease  Please enter the Neuromuscular Disease.

Date of birth (mm/dd/yyyy)  Please enter the Date of birth (mm/dd/yyyy).

Email Address  Please enter the Email Address.

Phone Number

Address (please include city, state & zip)  Please enter the Address (please include city, state & zip).

I authorize MDFF to use & share information I have provided (type name below)  Please enter the I authorize MDFF to use & share information I have provided (type name below).

Tell us about a time you have shown courage, resilience, and/or perseverance: 

This is an essay question. Please type your narrative answer into a Word document first so that you have it saved, then copy and paste it into the below box when you are ready to submit it. (1000 word max)

Please enter the Tell us about a time you have shown courage, resilience, and/or perseverance:.

How do you plan to use this award in pursuit of a dream or goal? 

This is an essay question. Please type your narrative answer into a Word document first so that you have it saved, then copy and paste it into the below box when you are ready to submit it. (1000 word max)

Please enter the How do you plan to use this award in pursuit of a dream or goal?.

 

The is invalid. Try again.

If you're a human, and see the following field, don't fill it out: