Clone of Operation KeepSafe iD Request Form, Revised 7-29-26

Operation KeepSafe® iD Application Form; Revised 8-1-26

PLEASE ALLOW UP TO 10 BUSINESS DAYS US TO CONFIRM THIS APPLICATION
GIFT CARDS AVAILABLE
RED ASTERISK * INDICATES REQUIRED FIELD(S)

ONE FORM PER MEDICAL ID REQUESTED.
TERMS & CONDITIONS

The Dementia Society of America's Operation KeepSafe® program provides a wearable medical ID through a pre-funded $50 GIFT CARD (with spending restrictions).

Please review these 10 Operation KeepSafe® GIFT CARD program elements:
1. One no-charge medical ID GIFT CARD is available for people living with impaired cognition (mild, moderate, or severe).
2. One no-charge medical ID GIFT CARD is also available for their non-cognitively impaired carer/caregiver/care partner.
3. The caregiver can request a medical ID GIFT CARD for themselves without having to request one for the person they care for.
4. Apply to receive a medical ID GIFT CARD online, while program supplies last. We update the top of the application to reflect supply status with "AVAILABLE" or "UNAVAILABLE."
5. Once it has been reviewed and approved, the Dementia Society will send you a set-limit pre-funded GIFT CARD.
6. Along with your GIFT CARD, you will receive a pre-selected medical ID vendor. You can visit their website, select and order an ID product from their online catalog, and apply the value of a single CARD to it. If they offer phone support, you can order that way as well.
7. Only one GIFT CARD per order may be used.
8. If you are ordering a medical ID for both yourself and the person you care for, you must complete two separate GIFT CARD application forms. You must order the medical IDs separately, too.
9. We provide one no-charge medical ID GIFT CARD per person in their lifetime. If you decide to spend more than the value on the GIFT CARD (including shipping/engraving), you must pay the difference.
10. GIFT CARD expires in 3 months. Any remaining value is returned to the Dementia Society of America.
ADDITIONAL TERMS AND CONDITIONS BELOW.
NOTICE TO THE PERSON FILLING OUT THIS FORM - WE CALL YOU THE FORM FILLER.
Please confirm your role. If you are requesting two GIFT CARDS, please fill out individual forms, one for yourself and one for the other person. Example: the person living with a cognitive impairment, and the care partner.
Please confirm that you have the legal rights and permissions to request a GIFT CARD on behalf of someone else.
FORM FILLER INFORMATION
Your (Form Filler) Full Name - Person filling out this form.

First NameLast Name
Your (Form Filler) Address - This is where we will send the GIFT CARD.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you learn about the program? Please provide as much information as possible, i.e., person's name, business/organization, address, phone, email, etc.
Your (Form Filler) Relationship to ID Wearer (Enter "SELF," if you are wearer): Spouse, Parent, Child, Grandchild, Friend, or write in another type of relationship:
Your (Form Filler) MOBILE Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
CONFIRM and RE-ENTER Your (Form Filler) MOBILE Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your (Form Filler) EMAIL
example@example.com
CONFIRM and RE-ENTER Your (Form Filler) EMAIL
example@example.com
PERSON WEARING MEDICAL ID
Full NAME of Person Wearing Medical ID

First NameLast Name
Nick Name of the Person Wearing Medical ID (If applcable)
Preferred Spoken / Written Language of the Person Wearing Medical ID (If other than English)
Gender of Person Wearing Medical ID
THIS DOES NOT IMPACT ELIGIBILITY, but we show donors the range of the people impacted. Please indicate the housing of the medical ID wearer:

Other
THIS DOES NOT IMPACT ELIGIBILITY, but we show donors the range of the people impacted. Please indicate the area in which the medical ID wearer lives:

Other
THIS DOES NOT IMPACT ELIGIBILITY, but we show donors the range of the people impacted. Please indicate the type of insurance the medical ID wearer has:

Other
THIS DOES NOT IMPACT ELIGIBILITY, but we show donors the range of the people impacted. Please indicate the age category of the medical ID wearer:
THIS DOES NOT IMPACT ELIGIBILITY, but we show donors the range of the people impacted. Please indicate the estimated annual household income (Social Security, other government benefits, wages, investments, etc. of everyone in the household combined) of the medical ID wearer:

Other
THIS DOES NOT IMPACT ELIGIBILITY, but we show donors the range of the people impacted. How many other people live in the household with the medical ID wearer:

Other
Birthdate of Person Wearing / Using ID

MonthDayYear
Date
Home Address of Person Wearing ID

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please share why this medical ID GIFT CARD is important to have:
I understand that the Dementia Society, Inc. d/b/a Dementia Society of America (DSA), and/or its assigns, are providing only a GIFT CARD, at no charge, that allows the user/buyer to purchase a medical ID from pre-selected vendors, subject to a maximum value limit.

I understand that DSA, and/or its heirs and assigns, assume no responsibility for the operation, performance, or outcomes for any particular purpose from the use of said medical ID products/services.

Failure of the medical ID products and/or services may result in delayed help, no help, bodily harm, and even death.

NO MATTER THE ISSUE: DSA'S MAXIMUM LIABILITY IS LIMITED TO THE MAXIMUM VALUE OF THE GIFT CARD (IN MOST CASES, USD $50)

DSA does share with donors and funders broad categories of those we serve. We do this to ensure that needs are being met across the widest cross-section of the US population.

TERMS AND CONDITIONS ARE SUBJECT TO CHANGE.

Revised 7-30-26
I HAVE READ AND CONFIRM ACCEPTANCE OF DSA TERMS AND CONDITIONS:
Do you have any questions or comments? If none, write NONE in the field below.
When you have double-checked your entries, print a copy for your records, then click "SUBMIT" below.
Should be Empty:

Operation KeepSafe® iD Application Form; Revised 8-1-26

NOTICE TO THE PERSON FILLING OUT THIS FORM - WE CALL YOU THE FORM FILLER.

FORM FILLER INFORMATION

PERSON WEARING MEDICAL ID