Application
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Application...please complete the below application checking all applicable boxes at the end.
Name
Address
Child's name
Child's Date of Birth
Date of Injury---by putting a date here I am confirming that my child has a diagnosis of brain injury.
Child
Male
Female
Current Age
Parents email address
Home Phone
Cell Phone
What happened
3 things child wants/needs- something under $100, under $1000 and any amount
Please email picture to info@childrensbraininjury.org. Anything else you want us to know?
I agree to allow Children's Brain Injury Association, Inc to publish my child's story/picture on their website or other media.
Yes
No
Please sign my child up for the Christmas Gift Program. Participation in the program is not a guarantee of a gift or a specific amount of a gift. Gifts are determined by the Board of Directors based on the availability of funds.
Yes
No
I would like to volunteer to help Childrens Brain Injury help other children.
Yes
No
