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Thank you for participating in our Direct Help Program. Our mission is to provide services, medical necessities, and educational tools to families who live in Central California that are affected by Autism. Please fill out this application in its entirety printing clearly. Illegible applications will not be considered.

DIRECT HELP APPLICATION

(Click here to download Application in Spanish)

Privacy Statement:

The information included in this application will remain private and confidential and is used for Foundation use only.

Autistic Child (if requesting aid far more than one autistic child, please fill out a separate application):

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Mother/Legal Guardian

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Father/Legal Guardian

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Dependent Children Information:

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Doctor(s) involved in child’s diagnosis and/or treatment of autism:

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Requested Items to be purchased by Foundation if grant is awarded:

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Note: Please be very specific with your description of monetary help or items needed for your child. At no time will money be awarded directly to families. All grant offerings are paid directly to the vendor and/or service provider. This may include tuition for specific classes, supplements/medication, medical evaluations, learning materials, testing, therapies, etc.

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Required Documents: This application will not be considered until all supporting documents are received.

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***Please reassure that ALL NECESSARY documents are uploaded

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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.

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Parent(s)/Guardian(s): All legal parents must print name below. All printed names are considered signatures.

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