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Mind Your Brain Fund Application

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Demographic information

Name*

Age*

State in which you reside

Phone*

Email*

Alternative contact/caregiver name

Alternative contact/caregiver Phone

Alternative contact/caregiver Email

Preferred method of communication

Phone

Do you need assistance with communication? If so, please share how we can best communicate with you.

Are you employed?

Yes

Occupation*

Job Type*

Full Time

Part Time

Are you in school?*

Yes

School Type*

High School

Bachelors

Masters or above

Current funding/programs

Are you currently receiving services/funding from any of the following programs?

Medicaid

Medicare

Workers Compensation

No Fault Auto/Auto Insurance

Home and Community based services/Medicaid Waiver, such as Community Health Choices (PA), Traumatic Brain Injury Waiver (NJ)

Head Injury Program of Pennsylvania (PA)

Traumatic Brain Injury Fund (NJ)

Office of Vocational Rehabilitation (PA)

Division of Vocational Rehabilitation Services (NJ)

Reason for your request

What are you requesting funding for? Please describe in detail.*

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Contact Information

Please contact navigator@mindyourbrainfoundation.org for any questions or if you need assistance with the application process.

Contact Us

Address:
43 Paoli Plaza #1127
Paoli, PA 19301
Email: info@MindYourBrainFoundation.org
Phone: 610-952-2768

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Your donation will help to support Mind Your Brain Foundation’s mission to provide meaningful and relevant patient-centric conferences designed for TBI survivors and caregivers.

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