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Fire Prevention
Fire Safe Kids
Fire Safe Seniors
Fire Safe Workplace
Youth FIre Setter Intervention
Resources
Burn Survivors
Programs
Camp Beyond the Scars
Burn Survivor Events
World Burn Congress Application
Our Impact
Get Involved
Special Events
Ways to Give
Supporters
Volunteer
Internship
About Us
Our Mission
Our Team
Careers
Contact Us
Financials
News
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Burn Survivor Intake Form
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Burn Survivor Intake Form
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Burn Survivor Intake Form
Burn Survivor Intake Form
This Form is private and confidential.
Patient's Name
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Gender
Male
Female
Non-Binary
Prefer Not To Say
Ethnicity
American Indian
Asian/Pacific Islander
Black/African American
Hispanic/Latino
Two or More Races
White
Gross Household Income (income will not exclude Burn Survivor)
*
Patient is a Minor
Yes
Parent/Guardian 1 Name
*
First
Last
Parent/Guardian 1 Role (Mother, Father, Aunt, etc...)
Parent/Guardian 1 Email
Parent/Guardian 2 Name
First
Last
Parent/Guardian 2 Role (Mother, Father, Aunt, etc...)
Parent/Guardian 2 Email (Must be different from 1st Parent/Guardian's email)
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number
*
Email
Burn Information
Cause of Injury
Car Fire
House Fire
Electrical Fire
Fire Play
Scald
Other
If you selected "Other" cause of injury, please describe:
Burn Type
Incident Description
Are you a caregiver requesting service on behalf of a burn survivor?
Yes
Caregiver Information
Caregiver Name
First
Last
Caregiver Email
Caregiver Phone
Relationship to Burn Survivor
Resources and Additional Information
Resources Requested/Interested In: (please do not select a resource if the age range does not apply)
Family Retreat (0-7 yrs)
Yes
Camp Beyond the Scars (8-17 yrs)
Yes
LIT Program at Camp (18-25 yrs)
Yes
Young Adult Burn Survivor Retreat (18-25 yrs)
Yes
Adult Burn Survivor & Caregiver Retreat(25+ yrs)
Yes
One Day Events/Meetups
Yes
Burn Survivor Circle of Friends (18+)
Yes
Young Adult Program (18-25 yrs)
Yes
Davee Scholarship
Yes
Financial Assistance (EN/SA)
Yes
World Burn Congress Scholarship
Yes
Winter Faire
Yes
Notes
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