Book Form

1Buyer Identification
2Contact Information
3Organization Details
4Order Type
5Preferred Date and Notes

Buyer Identification

Who are you ordering for?(Required)
Which state are you located in?(Required)
Are looking for Printable or Print-Outs?(Required)

Contact Information

Name(Required)
Email(Required)

Organization Details

Order Type

What would you like to order?(Required)
Price: $1.50
Price: $1.50

Preferred Pickup Date

MM slash DD slash YYYY

Additional Notes

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Event Sponsorship

Step 1 of 3

33%
Please enter the name of the event that is being sponsored.
Please enter the name of your organization.
Please enter your organization's website.
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)
Your Email Address(Required)
Are you the primary contact for this sponsorship?(Required)
Name of Primary Contact(Required)
Email of Primary Contact(Required)
Consent(Required)
Billing Address

Testimonial Submission

Tell us about your use of the 911 Ready bags.

This field is for validation purposes and should be left unchanged.
Name(Required)
MM slash DD slash YYYY
Max. file size: 512 MB.
Do you need to be contacted?(Required)

Share Your 911READY Bag Experience Form

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

MM slash DD slash YYYY
Time(Required)
:
Name(Required)
Prefered Contact Method(Required)
I am a responder in the following field(Required)

Station/Department Address(Required)
Please only select this box if you wish to remain anonymous.

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)
MM slash DD slash YYYY
Time(Required)
:
Please select your department type(Required)

Name(Required)
Department/Station Address(Required)

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)

Address of Station/Department/Company(Required)
Your Name(Required)
911READY Bag Program(Required)
How did you hear about the 911READY Program?(Required)

Max. file size: 512 MB.

Autism Optimism

Parent One Name(Required)
Parent Two Name
Address(Required)
Children List(Required)
Child Name
Date of Birth
Weight
 
Adults Only Understanding(Required)
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). 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.

Autism Ice Breaker

Participant's Name(Required)
MM slash DD slash YYYY
Emergency Contact Name(Required)
Participant Address(Required)
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.
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.
MM slash DD slash YYYY

Autism Ice Breaker

Participant's Name(Required)
MM slash DD slash YYYY
Emergency Contact Name(Required)
Participant Address(Required)
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.
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.
MM slash DD slash YYYY
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Young Adults

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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.

Name(Required)
Email(Required)
Department(Required)
Your Role or Title(Required)
City and State(Required)

Young Adults Annual Enrollment

Parent One Name(Required)
Parent Two Name
Address(Required)
Child Name(Required)
Attend School?(Required)
School Supports(Required)
Communication(Required)
Do they use an AAC for communication?(Required)
Toileting(Required)
Can they read?(Required)
Do they have a job?(Required)
Do they drive?(Required)
Do they have a phone?(Required)
Do they know their home address phone number?(Required)
Can they shop, make purchases independently?(Required)
Can they order off a menu?(Required)

Community Service

Name(Required)
Address(Required)
Are you over the age of 18 years?(Required)
MM slash DD slash YYYY
Emergency Contact Name(Required)
Do you have friends or family members who are employed by or volunteer for Mimi's Mission?(Required)
Have you ever been convicted of a crime?(Required)
Is this community service court ordered and/or required by a school, job, organization or agency?(Required)
MM slash DD slash YYYY
Statements(Required)
You must agree to all of the following statements by clicking the checkbox.
Please type your name.

Annual Enrollment Form

Step 1 of 5

20%

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.
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)

    Parent Two

    Parent Two Name

    Address

    Address(Required)

    Emergency Contact

    Emergency Contact Name(Required)

    Children Information

    Child 1 Name(Required)
    MM slash DD slash YYYY
    Is child 1 autistic?(Required)
    1) Do you have more children?(Required)

    Child 2

    Child 2 Name(Required)
    MM slash DD slash YYYY
    Is child 2 autistic?(Required)
    2) Do you have more children?(Required)

    Child 3

    Child 3 Name(Required)
    MM slash DD slash YYYY
    Is child 3 autistic?(Required)
    3) Do you have more children?(Required)

    Child 4

    Child 4 Name(Required)
    MM slash DD slash YYYY
    Is child 4 autistic?(Required)
    4) Do you have more children?(Required)

    Child 5

    Child 5 Name(Required)
    MM slash DD slash YYYY
    Is child 5 autistic?(Required)

    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.
    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.
    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.
    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.
    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.
    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.
    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.
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