Please fill out an application for the Rad Dad TBI Fund. Our board will review your application and get in touch with you. Order Number 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 Add File 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? Yes No What is the date of the injury? Upload medical documentation confirming the diagnosis of TBI Add File Was the Survivor’s TBI caused by an accident? Yes No Did the Survivor have long-term care insurance at the time of the accident? Yes No Is the Survivor able to generate an income above $50,000 per year after the accident? Yes No Is the Survivor deceased? Yes No Information Summary