BurnNet Caregiver Peer Support
This group is intended for caregivers and loved ones of burn survivors. To honor those support needs, we ask that all participants identify within these categories. Basic Ground Rules will be shared to create a supportive setting.
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Email *
Name (First and Last) *
Phone Number with Area Code *
Phone Type *
Street Address with unit if applicable *
City *
State (ie CA or WA) *
Zip Code *
For safety purposes, please tell us if you will be at home or at a different location for the virtual meeting. *
If not home, where? Please include the alternative address below.
Community Affiliation *
Required
Please check the dates you plan to attend. If you choose multiple sessions in advance, you will not have to fill out this form again for that session. Group will take place from 12-1:00pm PDT. *
Required
By checking this box, I understand that in joining this group I will be invited to actively participate and engage. *
Required
This virtual meeting is being brought to you through partnership between the UC Davis Burn Center and the Firefighters Burn Institute (FFBI). Please acknowledge that these organizations will store your registration information as part of your participation. *
Required
A copy of your responses will be emailed to the address you provided.
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