Burn Survivor Support Form

Burn Survivor Assistance

Connect With Our Support Team

If you're a burn survivor seeking assistance, we're here to help you connect with our organization. Simply complete the form below, and a team member will reach out to provide support tailored to your needs.

Burn Center *

Staff Name

Today's Date *

Burn Survivor’s Name *

Burn Survivor’s Date of Birth *

This information is used for age-specific programs and services

Burn Survivor’s Gender *

Mailing Address *

City *

State *

Country *

Postal code *

Email *

If under 18yo, please include guardian’s email

Phone Number *

If under 18yo, please include guardian’s number

Injury Date *

Guesstimates are fine

Type of Burn Injury *

This information is used for specific programs and services

Length of Hospital Stay *

Preferred Language *

Services and Programs *

Financial Assistance

Support Groups (Burn Survivor/Friends and Family Discussion meetings)

Recreational Programs (Camps, activities, and events)

Resources (Literature and videos for burn recovery)

Peer Support (Phone/video/in-person conversations with another burn survivor)

Please check all areas of interest

Additional Comments

Full Name *

Signature of Release *

Clear

By entering your name above, you confirm and acknowledge the information provided. If the burn survivor is under 18 years of age, a parent or legal guardian must sign on their behalf.

By releasing your personal contact information, you are allowing the Foundation to contact you directly. At any time, you may request to be removed from the database.

To opt out please email [email protected]

Our Family, helping yours.

The Firefighters of Southern Nevada Burn Foundation consists of active fire department personnel providing support to victims of fires & catastrophic events. The Burn Survivor Initiative raises funds to help more children attend seasonal burn camps, receive counseling and attend school reintegration programs. The Burn Foundation also collects toys for the disadvantaged children throughout the valley, and have provided at least one toy to thousands of children in need during the holidays.

Contact Us:

(702) 485-6820

Headquarters:

3111 S Valley View Blvd B 111, Las Vegas, NV 89102, USA

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