The Health Foundation of Greater Indianapolis is pleased to offer a grant to support the inscription of up to 30 Loved Ones' names on to the Indiana AIDS Memorial for families and friends of those who have passed due to complications of HIV and cannot afford the $100.00 cost. Please complete the form below with your name and contact information, along with the information of the Loved One whose name you would like to have inscribed.

* 1. Address

* 2. Please list the complete name of a Loved One that you would like to have inscribed on the Indiana AIDS Memorial - if known, please also include the Year of Birth and the Year of Death