Complimentary Membership for Rehab Hospitals
Today's Date
*
-
Month
-
Day
Year
Date
Name of Person with Brain Injury
*
First Name
Last Name
Name of Family Member/Caregiver/Guardian
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Rehabilitation Hospital
*
Approximate Date of Discharge
-
Month
-
Day
Year
Consent
*
Yes, I would like to be contacted about support groups, resources, unmasking brain injury, or other opportunities by a BIANC staff member.
Yes, I consent to the offer of complimentary membership to the Brain Injury Association of NC.
Signature
*
Please verify that you are human
*
Submit
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