Autism Awareness Card Application

Card Holder Name*

First NameLast Name

Card Holder Date of Birth*

MonthDayYear

Card Holder Gender*

MaleFemale

Status of the Cardholder*

Child [infant to 12 yrs old]Teen [age 13-18]Adult [18 yrs old to 54 yrs old]Senior [age 55 and above]

Height*

Weight*

Blood Type*

Organ Donor*

Emergency Contact Name*

First NameLast Name

Emergency Contact Relationship to Cardholder*

Emergency Contact Phone Number*

E-mail*

example@example.com

Card Holder's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Status*

Medical Conditions*

Are there any additional medical conditions*

YesNo

Additional Medical Conditions

Allergies?*

YesNo

List of Allergies

Would you like an additional card*

YesNo

How many additional cards would you like?

Additional Emergency Medical Condition Cards

Select Pickup Date:

Upload Photo of Cardholder*

Applicant's Signature

Applicant's Name

First NameLast Name

Terms and Conditions

Autism Awareness Cards are being provided FREE OF CHARGE and as part of Phoenix Innovation's "Committment to the Community" campaign. The applicant's signature hereby affirms the following: (1) the applicant hereby agrees that Phoenix Innovation shall be held harmless and not liable for any abuses or misuse of this card; (2) Furthermore, the signer of this application affirms that he or she is empowered to request the Autism Awareness Card.

The applicant understands that (1) Phoenix Innovations does not conduct any type of fact-checking as to the provided information, including but not limited to any medical information provided; (2) Phoenix Innovations shall not be held liable for any abuse or misuse of any medical information provided.

All information provided on the application shall only be used for the purpose of creating the card. The information will not be sold to or released to any party without proper legal authority and permission or as a result of legal process. There will not be any duplicate cards produced after the application process has been completed and the card(s) have been produced. Any cards that have not been picked up by the session's end will be destroyed immediately. All applications will be treated with the utmost protection to ensure that only those authorized to receive information are the only parties to receive information.