Brain Injury Society
Chaina Radomsky Hochman and Edythe Hochman Fogel
Bikur Cholim
Serving Acquired and Traumatic
Brain Injury Individuals and their Families
1901 Avenue N - Suite 5E
Brooklyn, NY 11230
Phone: 718-645-4401
E-mail:
[email protected]
Website: http://www.virtualtrials.com/bc
Donations
To make a donation, please fill out this form, THEN print it out, and mail it to the above address!
To donate by credit card or on your telephone phone bill - click here to go to our secure page!
Please make checks out to:
Brain Injury Society
Donations support the important work of the Brain Injury Society, an organization that assists the survivors of acquired and traumatic brain injuries.
INFORMATIONAL SHEET: please tell us about yourself
Name:
Address:
City, State Zip:
Country:
Daytime Phone:
Evening Phone:
What is best time for us to call you:
Daytime
Evening
Email:
Are you a:
Survivor
Family Member
Friend
Interested Individual
Professional
If a Brain Injury Professional, what is your field:
CONTRIBUTING MEMBERSHIP CATEGORIES:
FINANCIALLY RESTRICTED DUE TO
BRAIN INJURY SPECIAL RATE
$5
FAMILY
$50
SURVIVOR
$35
PROFESSIONAL
$100
ADVOCATE
$35
SUPPORTER
$50
DONOR
$75
MENTOR
$100
INSTITUTIONAL
$250
PATON
$500
SPONSOR
$1000
PHILANTHROPIST
$5000
Other (specify):
If you would like to charge this to your credit card:
Name as it appears on card
Amount
Your contributing membership assists the brain injury society in efforts on behalf of recovering individuals who desire a qualitative life after brain injury. Thank You.
Your genorosity assists recovering individuals, please inform us of your areas of interest (check all that apply):
ANNUAL DINNER
ALTERNATIVE MEDICINE
CLERICAL
COMMITTEE DEVLEOPMENT
COGNITIVE REMEDIATION
CONFERENCES
COGNITIVE ABILITY AND
EXERCISE CORRELATION ISSUE
DIAGNOSIS (AT
PRIMARY CARE LEVEL)
DISIPLINES
EDUCATION
EMERGENCY CARE ISSUE (DIAGNOSIS)
FORUMS
FUNDRAISING
INKIND SERVICES
INSURANCE ISSUES (DECLINING
COVERAGE & REIMBURSEMENTS)
JOURNAL
LEGAL/LEGISLATIVE ACTIONS/ISSUES
NEWSLETTER
MEDICAL ISSUES
MEMBERSHIP DEVELOPMENT
MULTIDISIPLINES
NEUROPSYCHOLOGICAL ISSUES
NETWORKING
OUTREACH
PROGRAMMING
PUBLICITY
POLITICAL ACTIVISM
REHABILITAION ISSUES
SEMINARS
SPEAKING
SUPPORT GROUP FACILITATOR/LEADER
"WOE IS ME" CLUB ISSUE
WORKSHOPS
If you would like to volunteer, what days are you available (check all that apply):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Morning
Afternoon
Evening
