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DIRECT HELP APPLICATION


  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.  


Privacy Statement:

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


Child with Autism (if requesting aid for more than one 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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3. A recommendation letter from a Physician, Speech Therapist, Behavioral Therapist, or Licensed Psychologist that states how the requested item(s) will directly aid your child with his/her autism. This is only required if you are requesting an item other than tuition for a specific class for autism, supplements/medication, medical evaluations, learning materials, testing, or therapies.

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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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