Participant Consent Form

I have read, or had read to me, the informed consent statement, house rules, and internet safety guidelines. I had the opportunity to ask questions and agree to take part in the hybrid brain injury support group.

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I will usually attend: *

• In-person
• Online
• Both

Participant Name *

First

Last

Notifications preferences *

• Email
• Phone (text)
• Phone (voice)

Email is required for all KBI & TBI Klatch notifications *

Phone

Usual location (city) when joining online; address is optional

Emergency contact name & relationship *

Emergency contact phone *

Accommodations that would help me

Participant Signature *

I have read, or had read to me, the informed consent statement, house rules, and internet safety guidelines. I had the chance to ask questions and agree to take part in the hybrid brain injury support group. You may e-sign or type full name to confirm.

Emergency Accommodations relationship

Date *

Facilitator Signature

Leave this field empty

Submit

If attending online, complete this form & submit prior to your first meeting

Attending in-person, you may submit prior to, or print this page & bring to your first meeting