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Programs
Resources
Burn Survivors
Programs
Camp Beyond the Scars
Burn Survivor Events
Applications
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Donate Now
Ways to Give
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Internship
About Us
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Burn Survivor Intake Form
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Burn Survivor Intake Form
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Burn Survivor Intake Form
This Form is private and confidential.
Patient's Name
*
First
Last
Date of Birth
*
Date Format: 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
