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Request for Services
You must be 18 or older to complete this application. If you are under 18 years of age, please have your guardian complete this form.
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* Indicates required question
Email
*
Your email
First and Last Name of Burn Survivor
*
Your answer
First and Last Name of Care Giver (if applicable)
Your answer
Burn Survivor Date of Birth
*
MM
/
DD
/
YYYY
Mailing Address (Street, City, State, Zip Code)
*
Your answer
Burn Survivor Contact Number
*
Your answer
Which statement best describes you?
*
I am a burn survivor
I am or have been the care giver of a burn survivor
Other:
Date of Burn Injury
*
Your answer
Is burn survivor currently hospitalized?
*
Yes
No
How did your (your loved ones) burn injury occur?
*
Your answer
Services or items requesting. Please be as detailed as possible. To qualify for assistance, the client must be facing challenges related to a burn injury.
*
Your answer
Has Scars Uncovered provided you with assistance before? If so, when?
*
Your answer
Any additional comments/feedback
Your answer
We also welcome you to visit our "Burn Survivors United" Facebook Group. Please copy this link and insert it into your browser:
https://www.facebook.com/groups/847409822627016
Your answer
Would you like to be added to our mailing list?
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Yes
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