Brain Injury Mentor Program
Information Request
How did you hear about us? {"type":"text","name":"__generic","width":48,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
What is the best way to contact you for follow-up from this form?{"type":"checkbox","name":"__generic2","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Phone call\nText\nEmail\nVideo Chat"}
Personal Information:
Full Name: prefixMr.Mrs.Ms.MissDr. Prof.Hon.SirCllrMsgr.LadyLordGeneralCaptainFatherRevEarl{"type":"select","name":"__generic3","width":14,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"prefix\nMr.\nMrs.\nMs.\nMiss\nDr. \nProf.\nHon.\nSir\nCllr\nMsgr.\nLady\nLord\nGeneral\nCaptain\nFather\nRev\nEarl"}
: {"type":"text","name":"__generic4","width":65,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
First Name
{"type":"text","name":"__generic5","width":65,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Last Name
Email: {"type":"text","name":"__generic6","width":88,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Primary Phone Number: {"type":"text","name":"__generic12","width":35,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
Mailing Address:
{"type":"text","name":"__generic14","width":82,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
Street Address
{"type":"text","name":"__generic15","width":95,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
Street Address Line 2
{"type":"text","name":"__generic16","width":85,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
{"type":"text","name":"__generic7","width":50,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"City"}
{"type":"text","name":"__generic8","width":50,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"State"}
{"type":"text","name":"__generic9","width":18,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"Zip Code "}
select hereUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorra AngolaAnguillaAntigua and BarbudaArgentinaArmeniaAruba AustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbedosBelarusBelgiumBelizeBeninBermuda BhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodia CameroonCanadaCamp VerdeCayman IslandsCentral African RepublicChadChileChineChristmas IslandCocos (Keeling) IslandsColumubiaComorosCongoCook IslandsCosta RicaCote d'lvoireCroatiaCuba CaracaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGayanaHaitiHondurasHong Kong HungaryIcelandIndiaIndonesiaIran IraqIreland IsraelItalyJamaicaJapanJersey JordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacadamiaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherland AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcaim islandsPoland PortugalPuerto RicoQatarRepublic of the CongoRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartiSaint Pierre and MiquelonSaint Vincent and the GranadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia SeychellesSierra Leone SingaporeSlovokiaSlovaniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiSpainSri LankaSudanSurinameSvalbardeSwatiniSwedenSwitzerlandSyria TaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanatuVatican CityVenezuelaVietnamBrtish Virgin IslandsIsle of ManUS Virgin IslandsWallis and FatunaWestern SahraYemen ZambiaZimbabweOther{"type":"select","name":"Country","width":40,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"select here\nUnited States\nAfghanistan\nAlbania\nAlgeria\nAmerican Samoa\nAndorra \nAngola\nAnguilla\nAntigua and Barbuda\nArgentina\nArmenia\nAruba \nAustralia\nAustria\nAzerbaijan\nThe Bahamas\nBahrain\nBangladesh\nBarbedos\nBelarus\nBelgium\nBelize\nBenin\nBermuda \nBhutan\nBolivia\nBosnia and Herzegovina\nBotswana\nBrazil\nBrunei\nBulgaria\nBurkina Faso\nBurundi\nCambodia \nCameroon\nCanada\nCamp Verde\nCayman Islands\nCentral African Republic\nChad\nChile\nChine\nChristmas Island\nCocos (Keeling) Islands\nColumubia\nComoros\nCongo\nCook Islands\nCosta Rica\nCote d'lvoire\nCroatia\nCuba \nCaracao\nCyprus\nCzech Republic\nDemocratic Republic of the Congo\nDenmark\nDjibouti\nDominica\nDominican Republic\nEcuador\nEgypt\nEl Salvador\nEquatorial Guinea\nEritrea\nEstonia\nEthiopia\nFalkland Islands\nFaroe Islands\nFiji\nFinland\nFrance\nFrench Polynesia\nGabon\nThe Gambia\nGeorgia\nGermany\nGhana\nGibraltar\nGreece\nGreenland\nGrenada\nGuadeloupe\nGuam\nGuatemala\nGuernsey\nGuinea\nGuinea-Bissau\nGayana\nHaiti\nHonduras\nHong Kong \nHungary\nIceland\nIndia\nIndonesia\nIran \nIraq\nIreland \nIsrael\nItaly\nJamaica\nJapan\nJersey \nJordan\nKazakhstan\nKenya\nKiribati\nNorth Korea\nSouth Korea\nKosovo\nKuwait\nKyrgyzstan\nLaos\nLatvia\nLebanon\nLesotho\nLiberia\nLibya\nLiechtenstein\nLithuania\nLuxembourg\nMacau\nMacadamia\nMadagascar\nMalawi\nMalaysia\nMaldives\nMali\nMalta\nMarshall Islands\nMartinique\nMauritania\nMauritius\nMayotte\nMexico\nMicronesia\nMoldova\nMonaco\nMongolia\nMontenegro\nMontserrat\nMorocco\nMozambique\nMyanmar\nNagorno-Karabakh\nNamibia\nNauru\nNepal\nNetherlands\nNetherland Antilles\nNew Caledonia\nNew Zealand\nNicaragua\nNiger\nNigeria\nNiue\nNorfolk Island\nTurkish Republic of Northern Cyprus\nNorthern Mariana\nNorway\nOman\nPakistan\nPalau\nPalestine\nPanama\nPapua New Guinea\nParaguay\nPeru\nPhilippines\nPitcaim islands\nPoland \nPortugal\nPuerto Rico\nQatar\nRepublic of the Congo\nRomania\nRussia\nRwanda\nSaint Barthelemy\nSaint Helena\nSaint Kitts and Nevis\nSaint Lucia\nSaint Marti\nSaint Pierre and Miquelon\nSaint Vincent and the Granadines\nSamoa\nSan Marino\nSao Tome and Principe\nSaudi Arabia\nSenegal\nSerbia \nSeychelles\nSierra Leone \nSingapore\nSlovokia\nSlovania\nSolomon Islands\nSomalia\nSomaliland\nSouth Africa\nSouth Osseti\nSpain\nSri Lanka\nSudan\nSuriname\nSvalbard\neSwatini\nSweden\nSwitzerland\nSyria \nTaiwan\nTajikistan\nTanzania\nThailand\nTimor-Leste\nTogo\nTokelau\nTonga\nTransnistria Pridnestrovie\nTrinidad and Tobago\nTristan da Cunha\nTunisia\nTurkey\nTurkmenistan\nTurks and Caicos Islands\nTuvalu\nUganda\nUkraine\nUnited Arab Emirates\nUnited Kingdom\nUruguay\nUzbekistan\nVanatu\nVatican City\nVenezuela\nVietnam\nBrtish Virgin Islands\nIsle of Man\nUS Virgin Islands\nWallis and Fatuna\nWestern Sahra\nYemen \nZambia\nZimbabwe\nOther"}
Country
I am requesting information about the Brain Injury Mentor Program as a Choose OneBrain Injury SurvivorRelative of a Brain Injury SurvivorFriend of a Brain Injury SurvivorCaregiver of a Brain Injury SurvivorHealthcare ProviderAttorneyCorporation/EmployerOrganization, Club, Lodge, Camp, etc.School/University/Trade SchoolCharity or Non-Profit Organization{"type":"select","name":"__generic10","width":50,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Choose One\nBrain Injury Survivor\nRelative of a Brain Injury Survivor\nFriend of a Brain Injury Survivor\nCaregiver of a Brain Injury Survivor\nHealthcare Provider\nAttorney\nCorporation/Employer\nOrganization, Club, Lodge, Camp, etc.\nSchool/University/Trade School\nCharity or Non-Profit Organization"}
If services are for yourself, what are you looking to accomplish by participating in the Mentor Program?
{"type":"textarea","name":"__generic17","width":75,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
If interested in information about this program for someone other than yourself, who are you inquiring for, and why?
{"type":"textarea","name":"__generic18","width":75,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"Please include how you know the person services provided for, whether the person is a teenager or adult, and what focus they may benefit from by having a Mentor."}
Do you have any specific questions or comments we can answer?
{"type":"textarea","name":"__generic22","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
PERSONAL DATA
The provision of personal data (“Data”) in this form is voluntary and will be used for mentor-mentee matching in the mentorship program, or providing additional information about the program. If you fail to supply the Data requested herein, we may be unable to process your application for information, and you will be unable to submit this form.
The Data may also be used for any of the following purposes:
- providing mentorship program services;
- performing administrative matters, communication and liaison concerning the mentorship program, Vital Ability LLC and their respective associates or affiliates;
- promoting mentorship program and events;
- any other legitimate purposes as may be required, authorized or permitted by law
The Data may be used, stored, disclosed, transferred by the mentorship program to its associates and affiliates, any government department or regulatory body if required by law and any individuals/organizations associated with the mentorship program including its agents and contractors for the purposes specified above.
If you would like to request access to and /or correction of the Data retained by us, please e-mail the mentorship program at myvitalability@gmail.com. Any requests for access to and correction of information will be dealt with as promptly as possible.
We are honored you have reached out to us and will be getting back to you as soon as possible.
Let's get started.
616-730-1204
