Where

This is an online event.

Contact

Danielle Krawiec
Brain Injury Association of Vermont
802-244-6850
dani@biavt.org

BIAVT 2021 Directory Inclusion Form

In an effort to continue improving accessibility for the individuals we serve, we are working on creating an online directory with providers in different regions of Vermont. You can be included in this database at no cost, or if you are a “brain injury aware” organization you have the opportunity to be displayed as a “recognized professional".

* Required information

Personal Information

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  • List Email Address:

  • Fee

    Type Fee
    $50.00
    $200.00
    $500.00
    No Charge

Business Information

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Registration & Acceptance

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    I would like the free listing.

  • I understand that by choosing the free listing, I am forgoing the following benefits: • Special recognition on this directory. The name of your organization will stand out among the other organizations. • Your organization will receive a discounted rate for our annual conference, which allows for networking within the brain injury community. • Your organization will receive a number of free trainings (number dependent on size of your organization).

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    I would like the recognized professional listing. I have thoroughly read the rules and regulations page, and by checking this box I agree to all terms. Please check off below which member type you are applying for. Please include payment according to your listing type.

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Brain Injury Aware Attestation

  • If you are signing up for the Recognized Professional Membership, please read this document thoroughly for it is an agreement that you, your organization, or corporation is brain injury aware and must be completed. Please check each box and sign after completion of reading to contest that you are experienced and knowledgeable in the area of brain injury.

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    By checking each box I/We am/are an individual, organization, or corporation that:

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$9,999.99

Payment

Payment Method

  • Please make check payable to:
    BIAVT
    Brain Injury Association of Vermont
    1 Derby Lane
    Suite 2
    Waterbury, VT 05676

Payment Summary


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Yes, I would like to receive membership information

Register