Alabama Head Injury Foundation

Alabama Citizen Advocacy
Institute Day

Application for 2012 Participation
Mobile Area


This course has been designed for Alabamians with Traumatic Brain Injury and/or their families.

The session will be held March 1, 2012 at the Regency Church of Christ.

It will begin at 10 AM and conclude by 4 PM.

 

Minimum age to apply - 18

Full Name
Address 1
Address 2
City
State
Zip
Telephone Home:     Cell:
Email
Today's Date
   
1. I am a: Person with traumatic brain injury
Parent
Spouse
Family member
Service provider
Other
   
2. At what age did the traumatic brain injury occur?
 
3. What is the current age of the person with traumatic brain injury?
 
4. How did the traumatic brain injury occur?
   
5. If you work outside the home do you need a letter sent to your employer for verification of your absence?      
       Yes No    

        If yes, provide contact information below: 
        
   
6. If you are a person with traumatic brain injury, do you require someone to attend the sessions with you as a support?      
       Yes No    

7. What support, if any, do you need to participate? Please check:
Wheelchair Accessibility
Large Print
Interpreter Services Materials in Alternative Format
Dietary Other (Please explain.) 


There will be a $50.00 stipend available to participants who attend the entire day's session. This stipend should offset cost of gas or other expense of participant in order to attend. In the event of 2 people from the same household selected to participate, only 1 stipend will be awarded per household.

The Citizen Advocacy Institute is limited to 20 participants. 
A selection committee will review and select participants. 


Complete this online application and submit. If you need assistance or prefer to fill out an application over the phone, call Ms. Koplon at 1-800-433-8002.

This project is supported in part by grant H21MC06738 from the Department of Health and Human Services (DHHS) Health Resources and Services Administration, Maternal & Child Health Bureau.