BIAA Education Task Force Volunteer Form

Question Title

* 1. Volunteer Contact Information

Name

Company

State/Province

Email Address

Phone Number

Question Title

* 2. Your connection to brain injury (check all that apply)

Psychologist

Medical Professional

Licensed Therapist

Social Worker

Administrator/Executive

Student

Family Member

Caregiver

Educator

Person with Brain Injury

Other (please specify)

Question Title

* 3. For professionals, how many years have you worked with persons with brain injury?

Question Title

* 4. Certifications/licenses held

Question Title

* 5. Previous committee or volunteer experience

Question Title

* 6. Why are you interested in serving on the BIAA Education Task Force?