Application | RAD DAD TBI

Please fill out an application for the Rad Dad TBI Fund. Our board will review your application and get in touch with you.

YOUR Full Name

YOUR Email Address

Your relationship to the Survivor

Name of Injured Survivor’s Primary Contact

Relationship of Primary Contact to Injured Survivor

Name of Injured Family Member You Are Nominating

Relationship of Primary Contact to Injured Survivor *

Contact Number of Primary Contact

Alternate Contact Number

Email Address of Primary Contact

Picture of Individual / Family

Tell Us A Little About The Survivor & Their Need

If your application is approved, are you able to email receipts &/or bank statements for reimbursements?

What is the date of the injury?

Upload medical documentation confirming the diagnosis of TBI

Was the Survivor’s TBI caused by an accident?

Did the Survivor have long-term care insurance at the time of the accident?

Is the Survivor able to generate an income above $50,000 per year after the accident?

Is the Survivor deceased?