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The full library of Mimi’s Mission forms.

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

Date(Required)

Time(Required)

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)

CAPTCHA

Name(Required)

First Last

Phone(Required)

Email(Required)

Enter Email Confirm Email

Department(Required)

Enter Department/Agency Name

Your Role or Title(Required)

Example: Chief, Captain, Lieutenant, Training Coordinator, Officer, Dispatcher

City and State(Required)

Enter City Enter State

Participant's Name(Required)

First Last

Participant's Date of Birth(Required)

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

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)

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

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

CAPTCHA

Name(Required)

First Last

Phone(Required)

Email(Required)

Number of adults(Required)

Number of children(Required)

1Buyer Identification

2Contact Information

3Organization Details

4Order Type

5Preferred Date and Notes

Buyer Identification

Who are you ordering for?(Required)

School / Educational Organization

Individual / Other Organization

Which state are you located in?(Required)

Michigan

Other

Are looking for Printable or Print-Outs?(Required)

Printable (Download)

Print-Outs (Physical Copy)

Name(Required)

First Last

Phone(Required)

Event Location(Required)

Location/event capacity(Required)

Location contact person(Required)

Cost (be specific if per person, group rate, renting out facility, etc.)(Required)

Date/Dates if applicable:

Other details

CAPTCHA

Step 1 of 3

CAPTCHA

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

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)

Billing Address

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

Your Comments/Questions(Required)

Date(Required)

Time(Required)

Name(Required)

First Last

Email(Required)

Phone with extension if needed(Required)

Prefered Contact Method(Required)

Phone

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.

CAPTCHA

Company

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)

Upload a department logo.(Required)

Max. file size: 512 MB.

Do you need to be contacted?(Required)

Yes

CAPTCHA

This field is hidden when viewing the form

Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

About You

Your Name(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City ZIP Code

How Can We Reach You?

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

Preferred Method of Contact

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Best Time to Call You(Required)

About your business.

Please give us a description of what your business does so we can better consider you for our event.

Description(Required)

Photo Release(Required)

By checking this box, you acknowledge and agree that photographs and/or videos may be taken of you and your vendor booth during the event organized by Mimi’s Mission. These photographs and videos may be used by Mimi’s Mission for promotional purposes, including but not limited to, social media, websites, and other marketing materials. As a vendor, you consent to the use of your image, your booth’s image, and any products displayed without compensation and waive any rights to inspect or approve the finished product. If you do not agree to these terms you will not be able to proceed with your application.

CAPTCHA

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

Open

911Ready Training Call

Complete the form below to request additional 911READY training support for your department or first responder team. Please provide a few details about your organization and what you would like to discuss. A member of the Mimi’s Mission team will review your request and follow up with you to coordinate the training call.

Open

Annual Enrollment Form

Open this form to get started.

Open

Autism Ice Breaker

Open this form to get started.

Open

Autism Optimism

Open this form to get started.

Open

Autism Safety Night Sign Up Form

Open this form to get started.

Open

Book Form

Open this form to get started.

Open

Community Service

Open this form to get started.

Open

Consideration for event/outing form

Do you have a great idea for an event or outing? Please fill out this form to let us know all about it.

Open

Department Participation Request Form

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

Open

Event Sponsorship

Open this form to get started.

Open

Share Your 911READY Bag Experience Form

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

Open

Testimonial Submission

Tell us about your use of the 911 Ready bags.

Open

Vendor Application

This form is for vendors to supply all their information for consideration.

Open

Volunteers

Open this form to get started.

Open

Young Adults Annual Enrollment

Open this form to get started.

Open

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Frequently Asked Questions

How do I receive information? +

The best way to stay informed is to follow Mimi’s Mission on Facebook. We regularly share updates about events, community resources, advocacy information, and ways to get involved.

Are events sensory-friendly? +

Yes. We plan quiet spaces, visual schedules, and flexible participation, with volunteers available at all times.

Contact & Location

Email Address:
office@mimismission.org

Address:
20050 Vreeland Rd
Woodhaven, MI
48183

All Forms

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

Parent One

Parent Two

Address

Emergency Contact

Children Information

Child 2

Child 3

Child 4

Child 5

Confirmations

Buyer Identification

Contact Information

Organization Details

Order Type

Preferred Pickup Date

Additional Notes

How Can We Reach You?

Next Steps: Sync an Email Add-On

About You

How Can We Reach You?

About your business.

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Frequently Asked Questions

Contact & Location

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