Hybrid BurnNet Survivors Meeting Sign-Up
This group is intended for adult burn survivors and their loved ones. To honor their support needs, we ask that all participants identify within these categories. Burn Care Professionals are welcome. Basic Ground Rules will be shared to create a supportive setting.
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Email Address *
Phone Number with Area Code *
Phone Type *
Date of Birth:
MM
/
DD
/
YYYY
Street Address *
City *
State *
Zip Code *
Country/Province/Region (if outside USA)
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.
Check the meeting(s) you plan to attend. This group takes place the first Thursday of each month from 6pm - 7:30 PST. This is a Hybrid meeting format -- you'll have the option to attend in-person OR online.  *
Required
Check the meeting(s) you plan to attend. This group takes place the third Thursday of each month from 11:30am - 12:30pm PST. *
Required
Would you like to receive the evening Zoom link every month regardless of registration status? *
Required
Would you like to receive the lunchtime Zoom link every month regardless of registration status? *
Required
How are you connected to the burn community? *
Required
How did you learn about the Virtual BurnNet Survivor Meeting?
By checking this box, I understand that in joining this group I will be invited to actively participate and engage. *
Required
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms