AVBI Mission Possible (Lumosity) Application


If you are a servicemember / veteran who suffered a brain injury and would like to continue to use Lumosity as part of your rehabilitation program please fill out the following application.  1 (One) year subscriptions will be provided to qualified AVBI members* who meet the eligibility requirements**. 

Fields marked with an *are required.
Veterans First Name:*
Veterans Last Name:*
Veterans Address:* City:*
State:* Zip Code:*
Phone number:* E-mail:*

(Veterans/Point of Contact Phone #)
(Email used to set up LUMOSITY) 
*Qualified AVBI Members: Servicemembers/veterans, having served “honorably”, who suffered a medically documented brain injury while in service to the United States Armed Forces.
**Eligibility Requirements: Applied for and have received the AVBI Medical Alert tag & ID Card AND have registered and participated in the Lumosity.com FREE trial period.
Have you received an AVBI Medical alert Tag & ID card?*
Have you registered for the Lumosity FREE trial period?*
How much time have you spent logged on to Lumosity.com, per day, during the trial period?
Are you currently receiving cognitive therapy with a certified therapist?
Do you feel the Lumosity program will enhance the other therapies you are receiving?
Do you feel the Lumosity program has the potential to assist with your overall recovery?
How many years since you suffered a brain injury?
Are you willing to participate in additional surveys about AVBI and/or Lumosity?

If other than the Servicemember/Veteran is filling out this application; please provide us with your information.
First Name:
Last Name:
E-mail: Relationship:
Telephone Number:

Additional Comments:

By clicking the "Submit Application" button you are sending us information you have provided. This submission authorizes American Veterans with Brain Injuries, Inc. (AVBI) to contact you in pursuit of your request of the Lumosity subscription. Additional information or medical documentation may be requested before we fulfill your request. Your information is safe and will be retained by AVBI; No information provided will be sold, transferred or distributed to a third party.