Caregiver AAA Gift Membership Application

Caregiver AAA Gift Membership Application
Introduction:

Thank you for your interest in seeking a one year pre-paid AAA gift membership from The Kristina Butler Foundation. Our Foundation is dedicated to supporting professional caregivers who provide essential home care services to individuals in need. Please complete this application to help us assess your eligibility for our Caregiver Support Program.

Application Guidelines:
- Applications are processed within 30 business days of cycle close. Submission does not guarantee assistance due to limited resources.
- For detailed assistance policies, please refer to The Foundation’s Assistance Policy here.
Cycle Information:
- During this cycle The Kristina Butler Foundation will be awarding a maximum of $4,000 in AAA memberships to qualified caregivers.
- Application submission period for this cycle will be open from May 1, 2026 to May 21, 2026 11:59 P.M. EST.
- Winners will be randomly selected and announced no later than June 1, 2026.
AAA Membership Information:
- Selected, qualified caregivers will receive a 1 year pre-paid AAA Gift Membership.
- The AAA Membership includes:
  - Roadside Hookup and Towing- 100 mile tows 4x/yr
  - Flat Tire Service
  - Battery Jump Start
  - Out of Fuel Service - Free fuel delivery
  - Up to $100 for Lockout Service
  - Stuck Vehicle Service
  - Bicycle Coverage
  - Identity Theft Monitoring
  - Up to $1,500 of Legal Defense Reimbursement (Legal fees for traffic charges)
  - International Travel Maps
  - $8.99 Passport Photos
  - Up to $1,000 Trip Interrruption Expenses
I am requesting support for
Your Contact Information
What is your name?

First NameLast Name
What is your phone number?
Please enter a valid phone number.Format: (000) 000-0000.
What is your email address?
example@example.com
What is your relationship to the person you are requesting a AAA Membership for?
Personal Information of the Caregiver:
Full Legal Name
Include all applicable: First, Middle, Last, Suffix
Date of Birth

MonthDayYear
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Eligibilty Criteria:
Have you, or anyone in your household, previously received support from the Kristina Butler Foundation?
Have you, or anyone in your household, previously requested support from the Kristina Butler Foundation?
Name of the person who previously requested support
Are you directly related to a current employee or board member of The Kristina Butler Foundation? This includes spouses, parents, children, siblings, or any other close relatives.
Eligibility Requirements for Caregivers:

To be considered for educational assistance, applicants must:
1. Be employed as a professional caregiver by a professional agency or home health / home care agency.
2. Reside in the United States.
3. Be at least 18 years of age at the time of funding.
4. Provide proof of caregiving responsibilities and employment status.
5. Successfully pass a background check in accordance with applicable laws.
Do you believe you meet all the above eligibility requirements?
Caregiving Experience

Please answer the following questions about your caregiving experience.
Do you have experience as a caregiver?
Are you a:

Other
Name of your Employer:
Phone Number of your Employer:
Are you a certified / registered caregiver?
Please provide the certification number and state of issuance:
Caregiver Status: When were you a caregiver?
Duration of caregiving experience
Average number of hours you provide care weekly:
Professional Reference Information

Provide contact information for a professional reference who can verify your caregiving experience
Reference's Full Name
Reference's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your relationship to this professional reference contact:
I authorize the Kristina Butler Foundation to contact this reference. (Please note, in order to determine your eligibility, we will need to contact your reference)
Electronic Signature:

By typing your name below, you agree that:
1. The information you provided in this application is truthful and complete to the best of your understanding.
2. Submitting this application does not guarantee funding from the Kristina Butler Foundation.
3. You have reviewed and agree to the eligibility criteria.
Electronic Signature [Type your full name here:]
First Name, MI, Last Name, Suffix
Calculation
Should be Empty:

Caregiver AAA Gift Membership Application

Your Contact Information

Personal Information of the Caregiver:

Eligibilty Criteria:

Caregiving Experience

Professional Reference Information