Nominate a Champion :: Riley Stories :: Riley Children's Foundation

Riley Stories

Nominate a Champion

Do you know someone between the ages of 8 and 18 who has been treated by Riley Hospital within the last three years and who should be a Riley Champion? Nominate them and tell us why. Please complete the form below and submit it to Riley Children’s Foundation.

Riley Champion Nomination Form * Childs Name: * Birthday/Age: * Clinical Area: * Riley Physician: * Dates Treated at Riley: * Childs School:

Parent's/Legal Guardian's Information * Parent/Guardian Name: * Mailing Address: * City: * State: * Zip: * Phone: * Cell Phone: * E-mail:

Nominated By: * Your Name: * Mailing Address: * City: * State: * Zip: * Phone: * E-mail:

About the Nominee: * How does this nominee and family inspire other in the community? * What was the nominee's injury or illness? * What does this nominee do to support Riley Hospital and Riley Children's Foundation in his/her community (i.e. partiicipate in Riley events: Radiothon, Kids Caring and Sharing, Dance Marathon)? * Please describe how this nominee embodies the spirt of a champion?

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