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Carlos Vieira Foundation Direct Help Application HELPING FAMILIES LIVING WITH AUTISM

Thank you for participating in our Direct Help Program. Our goal is help families, which have a child or children living with autism, to pay for specific items that will better their future or to help with medical costs associated with autism. Please fill out this application in its entirety and remember to print clearly as illegible applications cannot be considered.

Privacy: The information included in this application will remain private and confidential and for CVF use only.

Autistic Child (If requesting aide for more than one autistic child, please fill out a separate application):

Name: ___________________________________ Age: __________ Date of Birth: _______________________

Mother/Legal Guardian: Check here if you want return mail sent to this address Name: _______________________________________ Relation to Child: _________________________________ Marital Status: __________ Telephone: _____________________ Email: _________________________________ Street/City/Zip: ________________________________________________________________________________ Employer: _______________________________________________ Telephone: __________________________ Employer Address: _____________________________________________________________________________

Father/Legal Guardian: Check here if you want return mail sent to this address Name: _______________________________________ Relation to Child: _________________________________ Marital Status: __________ Telephone: _____________________ Email: _________________________________ Street/City/Zip: ________________________________________________________________________________ Employer: _______________________________________________ Telephone: __________________________ Employer Address: _____________________________________________________________________________

Shipping Address if different from mailing address: Street/City/Zip: ________________________________________________________________________________

Updated: 1/7/13

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Dependent Children Information: 1. Name:________________________________________Age:____________Autistic: Yes________ No________

2. Name:________________________________________Age:____________Autistic: Yes________ No________

3. Name:________________________________________Age:____________Autistic: Yes________ No________

4. Name:________________________________________Age:____________Autistic: Yes________ No________

5. Name:________________________________________Age:____________Autistic: Yes________ No________

Doctor(s) involved in child’s diagnosis and/or treatment of autism: Name: ______________________________________________ Phone: __________________________________ Address: _____________________________________________________________________________________ Name: ______________________________________________ Phone: __________________________________ Address: _____________________________________________________________________________________

Requested Items to be purchased by CVF if grant is awarded: Note: Please be very specific with your description of monetary help or items needed for your child. At no time will money be given directly to families. All grants awarded are paid directly to the vendor or service provider to pay for tuition, supplements/medication, medical evaluation, learning materials, testing, therapies, etc.

Item #1:________________________________________________________________COST: $________________ Service provider, vendor or place to buy items: ______________________________________________________ Item #2:________________________________________________________________COST: $________________ Service provider, vendor or place to buy items: ______________________________________________________ Item #3:________________________________________________________________COST: $________________ Service provider, vendor or place to buy items: ______________________________________________________ Yes, I want to sign my child up for MedicAlert GPS + Essential Membership. Offering includes GPS device,

MedicAlert Essential Membership, Medical ID Shoe Tag and 24/7 emergency support (Complete full application on last page.

Previous Grants: Have you previously received funding from Carlos Vieira Foundation? Yes_______ No_______ Year__________

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Liability Disclaimer: I hereby release, indemnify and hold harmless The Carlos Vieira Foundation for any injury or accident that may occur and I will assume all liability in connection with an injury (including any injury caused by negligence) that may occur with any of the awarded items associated with this Direct Grant program. By signing below I understand and agree to these conditions.

Parents/Guardians: (All legal parents or guardians must sign below) Print Name: __________________________________________ Signature: ____________________________________________ Date: ___________________ Print Name: ___________________________________________ Signature: ____________________________________________ Date: ___________________

Check off List:

You must mail in completed application

You must send in one of the following in order for your application to be approved (school IEP’s will not be accepted as diagnosis of Autism): 1. Proof of Diagnosis of Autism from a School Psychologist 2. Proof of Diagnosis of Autism from a Regional Center Psychologist 3. Proof of Diagnosis of Autism from a Private Psychologist

Required: Attach the most recent IRS return/s for both parents or guardians or applications cannot be considered.

If you are requesting an electronic device (i.e. computer, I-Pad, etc.) you will need to attach a recommendation letter from an ATP/RESNA, Assistive Technology Practitioner, Speech/Language Specialist or Occupational Therapist that states how this device will help your child specifically with his/her autism.

If you are requesting an electronic device (i.e. computer, I-Pad, etc.) you will need to complete the Electronic Device Form and include it with this application.

Include Sponsored Membership for Children completed form with your application if you are requesting MedicAlert GPS Device + Essential Membership.

Please keep a copy for your records

Please Note: 1. We cannot accept phone calls asking if applications have been received. As soon as the process is complete we will

contact you by mail whether you have been approved or not.

2. This application cannot be considered until this form is completed legibly, signed, and all supporting documents are received.

Mail completed application to: CARLOS VIEIRA FOUNDATION DIRECT HELP PROGRAM 257 E. Bellevue Road, PMB 5150 Atwater, CA 95301

Carlos Vieira Foundation HELPING FAMILIES LIVING WITH AUTISM

MEDICALERT ENROLLMENT INCLUDES:

Mail completed application to: MedicAlert Foundation, P.O. Box 819012, Turlock, CA 95381 or Fax to: 209.669.2495 (attn: Advancement Department)

SPONSORED MEMBERSHIP FOR CHILDRENTHROUGH THE CARLOS VIEIRA FOUNDATION

MEMBER INFORMATION

MEDICAL CONDITIONS / ALLERGIES / MEDICATIONS

• Live 24/7 emergency response services• Live 24/7 family notification services• One personalized MedicAlert medical ID shoe tag• One personalized MedicAlert medical ID bracelet• Emergency Health Record• Emergency wallet card

FIRST NAME MIDDLE NAME LAST NAME

MAILING ADDRESS CITY STATE ZIP

PHONE EMAIL ADDRESS

DATE OF BIRTH GENDER

PARENT / GUARDIAN NAME PARENT / GUARDIAN EMAIL

PARENT / GUARDIAN PHONE #1 PHONE #2

PRIMARY PHYSICIAN PHYSICIAN PHONE

Check the box next to each of your child’s conditions and write in any others not listed. While these conditions are very important, any condition that requires continued physician care or special attention in an emergency should be noted.

ALLERGIES: List all known food, drug or other allergies

MEDICATIONS: List all medications and dosages, including inhalers

Engraving: The MedicAlert® ID will be engraved with your child’s membership number and our 24-hour emergency response number, enabling responders to assist your child immediately. To provide the best service possible, our trained staff will determine what additional critical information (e.g., a medical condition) should be engraved on the ID.

Important: By accepting membership with MedicAlert Foundation, you authorize MedicAlert to release all information about your child in emergencies. MedicAlert relies upon the accuracy of the information you supply. As the parent/guardian, you agree to defend, indemnify, and hold MedicAlert (including its employees, officers, directors, and agents) harmless from any claim or lawsuit brought by you or others for injury, death, loss or damages arising in whole or in part out of your provision of incomplete or inaccurate information about your child to MedicAlert. Furthermore, as a parent/guardian for the child(ren) named above, you hereby represent and warrant to MedicAlert that you have full power and authority, as the duly authorized representative of the child(ren), to enroll and act on their behalf.

SIGNATURE OF PARENT/GUARDIAN DATE

q Asthmaq Autism q Congenital Heart Defect

q Cystic Fibrosis q Diabetesq Hearing Impairedq Hemophilia

q Implantq Seizure Disorderq Other

MedicAlert Foundation is a 501(c)(3) nonprofit organization. ©2014 All rights reserved. MedicAlert® is a U.S. registered trademark and service mark of MedicAlert Foundation International.

FREE MEDICALERT MEDICAL ID SHOE TAG

FREE MEDICALERT MEDICAL ID BRACELET (CHOOSE ONE)

STAINLESS STEEL SHOE TAG(For Shoe Laces)

SILICONE PLAY BRACELETS

SILICONE COMPETE BRACELETS

Select Bracelet Size q S (6”) q M (6.75”) q L (7.5”)

q A823 (Yellow)

q A824 (Violet)

q A826 (Red)

q A827 (Black)

q A828 (White)

q A825 (Green)

q A829 (Yellow)

q A830 (Purple)

q A832 (Red)

q A833 (Black)

q A834 (White)

q A831 (Green)