Parent/Guardian Information *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

About The Applicant *

First Name

Last Name

Applicant's Birthday

MM

DD

YYYY

Media Release Waiver *

Do you give SHOW consent to use photos and information about your child on their social media accounts? We will never use full names or information that would compromise your family. We believe that sharing the information and pictures of the children that we are helping will help grow our mission and help us reach other families in need.

Yes

No

HIPPA Waiver *

SHOW in Baldwin County, Alabama is a non-profit organization, which seeks to help families afford medical supplies and devices. In order for applicants to receive assistance from SHOW, it is necessary for the applicant to provide specific medical history and other sensitive information. While SHOW protects information provided to us by using standard and reasonable precautions, it is important that the applicant understands and acknowledges that SHOW is not a HIPPA covered entity, that SHOW is not a medical-care provider, and that HIPPA protections do not apply to SHOW.

I Understand

I DO NOT Understand

Confidentiality Agreement *

By submitting this application, you hereby agree that the specific dollar amount of any monetary assistance provided by SHOW shall be strictly confidential and not to be shared with outside parties, absent a specific agreement otherwise from SHOW. This allows SHOW to fulfill its mission in helping others, without the added burden of disclosing specific dollar amounts awarded in other cases. Each specific individual is different, with differing circumstances and needs, and it is the mission of SHOW to provide help on a case-by-case basis.

I Agree

I DO NOT Agree