Life Goes On Grant Application
Eligible recipients of this grant are residents of New England with moderate to severe Traumatic Brain Injuries.  Funds will be used to pay for therapies or services that support recovery.  
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Email *
First name of grant nominee *
Last name of grant nominee *
If the grant recipient is not the individual filling out this form, please provide the name and contact information of the person filling out this form. *
What is the relation to the grant nominee of the individual who is filling out the form? *
Date of birth of nominee *
Street address of nominee *
City of nominee *
State of nominee *
ZIP Code of nominee *
Phone number of nominee *
Reference: Name of individual who can verify nominee's TBI and it's severity. *
Contact information of the grant nominee's reference (phone and email address). *
What is the severity of the nominee's brain injury? How much does it effect their day to day activities? *
How long ago was the nominee's injury? *
Please briefly share the story of how the nominee received their TBI. *
What is the grant amount being requested for the nominee and, if approved, how will the grant funds be spent? *

What areas of deficit will benefit from this therapy or resource with the support of this grant?

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Please provide contact information (name and phone number) for therapy or resource.

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Would the nominee be willing to let us share their story on the Life Goes On website, social media page, etc? *
Does the nominee give permission for us to use their first name and how they will be using the grant awarded by Life Goes On?
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