Fluxx Productions Mutual Aid Request Form

Fluxx Productions Mutual Aid Request Form

Request mutual aid support from Fluxx Productions. Please read all instructions and provide accurate information.
Thank you for reaching out to Fluxx Productions. This form is for requesting mutual aid support.
- One request at a time: Please submit only one request at a time (processing time is 1–2 weeks).
- Funding availability: Mutual funds are limited and may not always be available. We will do our best to accommodate requests as resources allow.
- Accuracy of information: If funds are sent directly to you, or to a provider on your behalf, the information you must provide must match your valid state- issued ID (of the information you have given to the provider). Your personal information will only be used to connect you with services and will be kept private.
- Youth under 18: A parent or guardian must sign this form and emergency contact information wil be required.
- Medical disclaimer: Fluxx Productions is not a licensed medical provider. We cannot diagnose, prescribe, or recommend medical treatment. By submitting this form, you acknowledge that Fluxx Productions cannot be held responsible for any care you receive from external providers.
Contact Information
Full Legal Name*
Preferred Name
Pronouns
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*

MonthDayYear
Date
Ethnicity/Race
Are you under 18?*

YesNo
Parent/Guardian Name (if under 18)
Requested Service
Which service are you requesting?*

Acupuncture (Tucson Community Acupuncture Clinic – 2900 E Broadway Blvd. #170, Tucson AZ 85716)Food Box or Gift Card (pending availability)General Medicine (doctor’s copay or labs)HRT PrescriptionPsychiatric or Therapeutic ServicesOther (Please Specify) ________________________________________________
Provider Information (if requesting medical/therapy support)
Practitioner’s Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Area of Service (specialty)
Disclosure Agreement
By submitting this form, I acknowledge and agree to the following:
- I waive the right to hold Fluxx Productions, or its team members, responsible for malpractice, discrimination, or misdiagnosis from any medical treatment provided by practitioners I have chosen and that may be paid for by Fluxx Productions.
- I understand Fluxx Productions, and its staff, are not medical professionals, and do not make medical or therapeutic recommendations or provide diagnoses.
Applicant Signature*
Date*

MonthDayYear
Date
Parent/Guardian Signature (if under 18)
Should be Empty:

Fluxx Productions Mutual Aid Request Form

Contact Information

Requested Service

Provider Information (if requesting medical/therapy support)

Disclosure Agreement