Event Sponsorship

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Name of Event(Required)

Please enter the name of the event that is being sponsored.

Name of Sponsor(Required)

Please enter the name of your organization.

Website

Please enter your organization's website.

Logo Upload

Accepted file types: jpg, svg, png, pdf, Max. file size: 10 MB.

Please upload your organization's logo for use on promotional materials.

How Can We Reach You?

We would love to chat with you. How can we get in touch?

Your Name(Required)

First Last

Preferred Method of Contact

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Are you the primary contact for this sponsorship?(Required)

Yes

No

Name of Primary Contact(Required)

First Last

Email of Primary Contact(Required)

Email Address Confirm Email Address

Phone of Primary Contact(Required)

Best Time to Call(Required)

Consent(Required)

By checking this box, I confirm that the information provided is accurate and that our organization agrees to participate as a sponsor under the event’s terms and conditions.

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Comments/Questions(Required)

Testimonial Submission

Tell us about your use of the 911 Ready bags.

URL

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

City / Town(Required)

Department(Required)

Email(Required)

Phone

Tell us your story(Required)

Date(Required)

MM slash DD slash YYYY

Upload a department logo.(Required)

Max. file size: 512 MB.

Do you need to be contacted?(Required)

Yes

No

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Share Your 911READY Bag Experience Form

Experience form for first responders use of a 911READY Bag.

Date(Required)

MM slash DD slash YYYY

Time(Required)

Hours

:

Minutes

AM/PM

Name(Required)

First Last

Email(Required)

Phone with extension if needed(Required)

Prefered Contact Method(Required)

Phone

Email

I am a responder in the following field(Required)

Law Enforcement

Fire and Rescue

Emergency Medical Services

Other

Name of Station/Department(Required)

Station/Department Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

County(Required)

Station/Department Phone(Required)

Please share your recent experience using a 911READY BAG(Required)

Any additional comments about this experience?

Describe some positive outcomes from using the 911READY BAGS(Required)

Please only select this box if you wish to remain anonymous.

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911CARES: First Responder Request to Help a Child in Need Form

911CARES is a program created for Emergency Responders servicing Downriver* cities and townships to get specific necessities for a child in need in their community

(Required)

I am a first responder in a department/station serving a DOWNRIVER city or township in Michigan

Date(Required)

MM slash DD slash YYYY

Time(Required)

Hours

:

Minutes

AM/PM

Please select your department type(Required)

Law Enforcement

Fire & Rescue

Emergency Medical Service

Other

Name(Required)

First Last

Your Job Title or Position(Required)

Email (Must be a department or city email)(Required)

Best phone number to reach YOU, including extension if applicable(Required)

Department/Station Main Phone Number(Required)

Name of Station/Department(Required)

Department/Station Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Describe the item(s) you know a child in your community needs(Required)

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Department Participation Request Form

This form is for first responder departments to request involvement into the 911READY platform.

Please select your station, department, or company type.(Required)

Fire & Rescue

Law Enforcement

Emergency Medical Services

911 Dispatch

Other

Name of Station/Department/Company(Required)

What city (or cities), township(s) or region(s) do you service? (Please enter all of the cities/township/areas that you service)(Required)

Address of Station/Department/Company(Required)

Street Address Address Line 2 City ZIP Code

County(Required)

Your Job Title or Position(Required)

Your Name(Required)

First Last

Your Phone Number (followed by extension if applicable)(Required)

Your WORK Email IMPORTANT: For security purposes, we can only accept your department/station/company email address. Please DO NOT enter your personal email address.(Required)

911READY Bag Program(Required)

Yes, we are interested in participating in the 911READY Bag Program

No, we are not interested in participating in the 911READY Bag Program

We already participate in the 911READY Bag Program

If you have any specific questions or other information you would like to provide, please use the space below.

How did you hear about the 911READY Program?(Required)

My department/station/company is already participating in the 911READY Bag program and we would like to participate in then next phase of the 911READY Program: Emergency Preparedness Alert System for Individuals with Special Needs and/or Disabilities

I received an email with the link to participate from another emergency responder

Print material (brochure, sign, business card, etc.)

Social Media

Television or Radio

Another department participating in the 911READY Program(s)

A community member/resident

Through interaction with Mimi's Mission, the Michigan non-profit organization that helps autistic individuals and their families

Other

Upload your tax exempt paperwork here(Required)

Max. file size: 512 MB.

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Autism Optimism

Comments

This field is for validation purposes and should be left unchanged.

Parent One Name(Required)

First Last

Parent One Email(Required)

Parent One Phone(Required)

Parent Two Name

First Last

Parent Two Email

Parent Two Phone

Address(Required)

Street Address Address Line 2 City State ZIP Code

Children List(Required)

Child Name

Date of Birth

Weight

Adults Only Understanding(Required)

I understand this meeting is for adults only. No childcare will be provided.

Photo Use Consent(Required)

I give permission for Mimi's Mission to use photographs of me for any promotions (including but not limited to website, print, and social media)

I give permission for Mimi's Mission to use photographs of me for any promotions (including but not limited to website, print, and social media). By participating, I authorize Mimi's Mission to use any photographs taken at meetings and events on social media and for the purposes of marketing and fundraising. I also authorize the use of photographs of any children I have listed on this form.

Each child will receive a weighted blanket, noise-reducing headphones, a car decal, and visual options for hygiene skills.

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Autism Ice Breaker

Participant's Name(Required)

First Last

Participant's Date of Birth(Required)

MM slash DD slash YYYY

Participant's Phone(Required)

Participant's Email(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Emergency Contact Email(Required)

Participant Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Photo Waiver

I agree to the photo Waiver

By participating in the Autism Acceptance Group / Autism Ice Breaker, I authorize Mimi's Mission to use any photographs taken at meetings and events on social media and for the purposes of marketing and fundraising.

Digital Signature(Required)

I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature.

Today's Date(Required)

MM slash DD slash YYYY

Autism Ice Breaker

Participant's Name(Required)

First Last

Participant's Date of Birth(Required)

MM slash DD slash YYYY

Participant's Phone(Required)

Participant's Email(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Emergency Contact Email(Required)

Participant Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Photo Waiver

I agree to the photo Waiver

By participating in the Autism Acceptance Group / Autism Ice Breaker, I authorize Mimi's Mission to use any photographs taken at meetings and events on social media and for the purposes of marketing and fundraising.

Digital Signature(Required)

I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature.

Today's Date(Required)

MM slash DD slash YYYY

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911Ready

Beards, Beers, and Bucks Wild Game Dinner

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December 14, 2023 @ 5:00 pm – 11:00 pm

For Tickets Call 734-283-3228

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Parent One Name(Required)

First Last

Parent One Email(Required)

Parent One Phone(Required)

Parent Two Name

First Last

Parent Two Email

Parent Two Phone

Address(Required)

Street Address Address Line 2 City State ZIP Code

Child Name(Required)

First Last

Attend School?(Required)

Yes

No

Name of School(Required)

School Supports(Required)

IEP

504

none

Communication(Required)

Verbal

Non-verbal

Do they use an AAC for communication?(Required)

Yes

No

Toileting(Required)

Independent

Needs Assistance

Diapers

Can they read?(Required)

Yes

No

Do they have a job?(Required)

Yes

No

Do they drive?(Required)

Yes

No

Do they have a phone?(Required)

Yes

No

Do they know their home address phone number?(Required)

Yes

No

Can they shop, make purchases independently?(Required)

Yes

No

Can they order off a menu?(Required)

Yes

No

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Community Service

Facebook

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code Country

Email(Required)

Phone(Required)

Are you over the age of 18 years?(Required)

Yes

No

Date of Birth(Required)

MM slash DD slash YYYY

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Do you have friends or family members who are employed by or volunteer for Mimi's Mission?(Required)

Yes

No

Have you ever been convicted of a crime?(Required)

Yes

No

Is this community service court ordered and/or required by an organization or agency?(Required)

Yes

No

If you are need or want a specific number of community service hours, please enter the how many hours here.

Statements(Required)

You must agree to all of the following statements by clicking the checkbox.

I understand that after I submit my application, it will be reviewed and my eligibility for volunteer work will be determined. I agree to on-site training specific to my responsibilities.

As a volunteer for Mimi's Mission, I agree to abide by all applicable rules and regulations of the organization. I understand that I will receive no monetary benefits in return for my volunteer service and that Mimi's Mission may terminate this agreement at any time without notice for any reason. I understand a criminal background check may be required for certain volunteer opportunities and I hereby authorize Mimi's Mission to do a criminal background check if and when it is necessary. I understand that any misrepresentation or omission of facts on this application could be cause for rejection of the application or dismissal.

I hereby release and waive liability against Mimi's Mission, a non-profit corporation, its directors, officers, employees and agents and for and injuries or illness that I myself or my dependent may suffer in connection with any volunteer work for Mimi's Mission. Further, I agree that Mimi's Mission is not liable for any damage to my property or my dependent's property resulting from volunteer work at Mimi's Mission. I agree that this release is broad and inclusive as permitted by the laws of the state of Michigan .

I give permission for Mimi's Mission to use photographs of me for any promotions (including but not limited to website, print, and social media)

Electronic Signiture(Required)

Please type your name.

Annual Enrollment Form

Step 1 of 5

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Please Have a Parent or Guardian Fill This Out and Sign! If You're Not a Parent or Guardian, Your Submission Will Be Invalid.*

Residency Information

Recidency(Required)

Thank you for your interest in joining the Autism Acceptance Group. Please note, the Autism Acceptance Group (AAG) is a program for Michigan families with children on the Autism Spectrum. Proof of Michigan residency is required.

I understand that I must be from Michigan with proof of residence.

Proof of Michigan Residency(Required)

You must provide at least one bill such as a utility bill or lease agreement with your name at a SE Michigan address.

Drop files here or

Max. file size: 512 MB, Max. files: 3.

Parent One

Parent One Name(Required)

First Last

Parent One Phone(Required)

Parent One Email(Required)

Parent Two

Parent Two Name

First Last

Parent Two Phone

Parent Two Email

Address

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Emergency Contact

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Children Information

Child 1 Name(Required)

First Last

Child 1 Birth Date(Required)

MM slash DD slash YYYY

Is child 1 autistic?(Required)

Yes

No

List any disabilities for child 1

1) Do you have more children?(Required)

Yes

No

Child 2

Child 2 Name(Required)

First Last

Child 2 Birth Date(Required)

MM slash DD slash YYYY

Is child 2 autistic?(Required)

Yes

No

List any disabilities for child 2

2) Do you have more children?(Required)

Yes

No

Child 3

Child 3 Name(Required)

First Last

Child 3 Birth Date(Required)

MM slash DD slash YYYY

Is child 3 autistic?(Required)

Yes

No

List any disabilities for child 3

3) Do you have more children?(Required)

Yes

No

Child 4

Child 4 Name(Required)

First Last

Child 4 Birth Date(Required)

MM slash DD slash YYYY

Is child 4 autistic?(Required)

Yes

No

List any disabilities for child 4

4) Do you have more children?(Required)

Yes

No

Child 5

Child 5 Name(Required)

First Last

Child 5 Birth Date(Required)

MM slash DD slash YYYY

Is child 5 autistic?(Required)

Yes

No

List any disabilities for child 5

Confirmations

Group Participation(Required)

Before proceeding, I acknowledge and understand that the Autism Acceptance Group provides outings and resources based on limited availability. Signing of this form does not guarantee a spot at an event but is required prior to signing up for a Mimi’s Mission sponsored outing.

I understand we must be active participants within the group.

No Show(Required)

Sign up process for events or resources will be defined on the AAG facebook page. The demand is usually greater than spots available so if a family signs up and then does not show up they will be placed at the bottom of the priority list for upcoming events.

I understand if I do not show up I will be placed at the bottom of the list for upcoming events.

Individuals Attending(Required)

I understand that these events are to promote community, inclusion and growth for autistic individuals and their families. Attendees should be limited to the individuals on your sign up form unless other invitations are extended.

I understand that only individuals listed in this form may attend events unless a special invitation is provided.

Code of Conduct(Required)

By registering for and attending this event, I agree to adhere to the Mimi’s Mission’s Code of Conduct, which prohibits any harassing, abusive, or threatening behavior.

I understand that I must adhere to Mimi's Mission's Code of Conduct at all times.

Rule Adherence(Required)

I understand and agree to adhere to all rules established to ensure the safety of all attendees, including any minors or vulnerable populations present.

I understand that I must adhere to all established rules.

Removal(Required)

Mimi’s Mission reserves the right to refuse entry or remove any attendee who violates the Code of Conduct or poses a risk to the safety and well-being of others, without a refund. This includes arriving at events appearing under the influence or giving off the odor of alcohol or marajuana.

I understand that I may be removed for not following the rules.

Photo Waiver(Required)

By participating in the Autism Acceptance Group, I grant Mimi’s Mission, its representatives, employees, and agents permission to photograph, record, or otherwise capture images or video of me and any minor children listed on this form during meetings, events, or related activities. I authorize Mimi’s Mission to use, reproduce, and publish these materials in any media, including social media, print, and digital formats, for purposes such as promotion, marketing, public relations, and fundraising. I understand that no compensation will be provided and that all rights to the images belong to Mimi’s Mission. I release and hold harmless Mimi’s Mission, its officers, employees, and agents from any claims or liability arising from the use of such materials, and this authorization shall remain in effect unless revoked in writing.

I understand and agree to the photo waiver

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