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Fire Prevention
- Programs
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Burn Survivors
Our Impact
Get Involved
About Us
- Our Mission
- Our Team
- Contact Us
- News
- Financials

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Family Retreat Volunteer Application

Thank you for your interest in volunteering at our Family Retreat!

Mission: To provide a safe, supportive, and inclusive environment for families impacted by burn injury.

Part I. Volunteer Information
Name*
First Last
Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code
Email Address*
Phone Number*
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Occupation
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Have you ever worked with burn survivors before?
- Yes
- No
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Are you a new or returning volunteer for this retreat?
- New
- Returning
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Health Insurance Provider
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Primary Care Physician
Please list any allergies to food.
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Do you have any physical limitations or medical concerns? If so, please describe.
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Are you CPR/AED certified?
- Yes
- No
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CPR/AED Certification Expiration
Month
Day
Year
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CPR/AED Certification Type
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Are you First Aid certified?
- Yes
- No
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First Aid Certification Expiration
Month
Day
Year
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Do you have any other certifications that are applicable to this retreat?
Personal Background History
Have you ever been convicted, fined, place on probation or imprisoned?
- Yes
- No
Have you ever been accused of, convicted or of in any other way been involved in an allegation of a crime involving a child?
- Yes
- No
Have you ever been found liable for civil penalties or damages involving sexual or physical abuse of a child or children?
- Yes
- No
Are you now or have you ever been subject to any court order involving the sexual or physical abuse of a minor, including, but not limited to a domestic protection order or the termination of parent(s) guardian(s) rights?
- Yes
- No
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Name
First Last
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Phone Number
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Relationship to You
Image, Video, and Information Release
WE REQUEST YOUR PERMISSION TO FILM, PHOTOGRAPH OR INTERVIEW YOU TO HELP OUR EFFORTS IN INCREASING PUBLIC AWARENESS AND SUPPORT OF OUR PROGRAMS BY APPEARING IN PHOTOGRAPHS, VIDEO OR OTHER PUBLICITY THAT THE RETREAT MAY PRODUCE.
Please Check Below
- I DO AUTHORIZE THE BURN INSTITUTE TO USE PHOTOGRAPHS, VIDEOTAPES AND/OR INTERVIEWS OF ME TO FURTHER THEIR EFFORTS TO PROMOTE PUBLIC AWARENESS AND SUPPORT
- I DO NOT WISH TO BE PHOTOGRAPHED/INTERVIEWED
THANK YOU!
We will be in touch about further steps! If you have any questions, please contact Leilani at Lstone@burninstitute.org or 858-541-2277.

San Diego, CA

8825 Aero Drive, Suite 200
San Diego, CA 92123

P. (858) 541-2277

Imperial Valley, CA

612 J Street, Suite 3
Imperial, CA 92251

P. (760) 355-3175

F. (760) 355-0836

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Our Mission is to educate and inspire communities to reduce burn injuries and empower those affected by burn trauma.

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