ONLINE MEMORIAL RECOVERY APPLICATION

STEP 1

Complete the online application below. The online application allows you to upload documents. After you submit your application, complete Step 2 at the bottom of this page. 

Raymond Rountree Jr. Memorial Treatment and Memorial Recovery

2021 - 2030 Raymond Rountree Jr. Memorial Treatment and Recovery Scholarship

PATIENT INFORMATION

Mailing Address *
Mailing Address
City
State
Zip
Enter numbers only
Enter numbers only

EMERGENCY CONTACT INFO

Enter numbers only
Relationship to Patient *

STEP 2

Read and submit the Statement of Accuracy below.  Please complete STEP 1 first before signing below. .

Statement Of Accuracy & Applicant Certification

Statement Of Accuracy & Applicant Certification

I hereby affirm and certify that all the above stated information provided by me is true and correct to the best of my knowledge. I also consent that if chosen as a memorial recovery awardee, my picture may be taken and used to promote the Foundation’s memorial recovery program. (Awardee may waive photo due to unusual or compelling circumstances.) *
I hereby understand that if chosen as a memorial recovery awardee, according to the RRJr Foundation Memorial Recovery policy, I must abide to the following stipulations:

• Be present at any potential awards ceremony, events, and/or including any acknowledgment events

• Remit to the Foundation the appropriate information for my memorial recovery to be paid directly to my therapeutic institution (in this event Mile High Continuing Care Recovery and Treatment Center) for my enrollment in an Intensive Outpatient Program (IOP)

• I hereby understand I will not submit this application without all required attachments and supporting information. Incomplete applications or applications that do not meet eligibility criteria will not be considered for this memorial recovery.

• I understand that misrepresentation in any statement may be considered reason for disqualification and/or repayment of any memorial recovery. If I am awarded a memorial recovery, I agree to abide by all requirements and responsibilities of the award.

Do you abide to the stipulations? *