Examples of Community Service – Share Your Story

A Program of the Medtronic Foundation

Live On. Give On.

Step 1 of 6 - Provide information about your medical condition, treatment, and volunteer work (Philanthropy Activity)
Step 2 of 6 - Provide Personal Information

This Bakken Invitation Award application will take you approximately 30 minutes to complete. You may save your details at any time and return later to complete. If you have questions, Email or Call for assistance: +1 855-712-2972 (Toll Free) or +1 952-857-2127.

Please fill in the fields below.

Required *

Please tell us about your medical condition and the date you received your medical device or therapy.
This information will be public.

Disease/Condition*

Therapy*

Date Therapy Received*

Philanthropy Activity* (Please do not include therapy or product information)

Philanthropic Focus*

Step 2 - Providing Personal Information

Required *

First Name*

Last Name*

Email/Username*

Country*

State/Province/District/Other*

City*

Terms of Agreement * – I understand that by submitting my Story and voluntarily disclosing the information listed above, I am giving my permission to Medtronic Inc. and Medtronic Foundation to publish within the Bakken Invitation Web site, in promotion and advertising, and on third-party mobile and social networking services such as Facebook or Twitter (1) my full name; (2) hometown and country; (3) photographic image; (4) details of my community volunteer activities (as described above); (5) description of my chronic disease state, medical technology and device therapy (as described above); and (6) any other information provided above, without restriction or right to compensation or any requirement that I examine or approve any intermediate or final copy containing such image or testimonial. I also understand that this Web site may allow users (including myself) to contact/connect with other community members, unless I waive that option by checking the box to Opt-Out of Community Directory.

Community Directory Opt-out – I do not wish to contact, or be contacted by, other community members. I understand that my contact information will be private, but information submitted on the previous page will be shared on my public story.I understand that this website may allow users (including myself) to contact / connect with other community members, unless I waive that option by checking the box to Opt-out of Community Directory.

Send me future communications regarding the Bakken Invitation.

How did you hear about the program?*

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