• Previous support details

    Please confirm what the location and date of your previous support.
  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
  • Your details

  • Your home phone number
  • Your mobile phone number
  • Enter your personal email address i.e. NOT your work email address.
  • Please enter organisation that referred you to The Fire Fighters Charity ( benevolent fund/charity, trade union etc.)
  • Please tell us a little bit about why you need support
  • Consent Clause

    • • I declare that the information I have provided is true and accurate, to the best of my knowledge and undertake to inform you of any changes in my circumstances that might affect my application
    • • I understand that the information I have provided will be used to process this application
    • • In the event that my application for rehabilitation services is not progressed, I authorise The Fire Fighters Charity to share with my referring organisation the reason why my application was not taken forward
  • Please tick the box below to confirm you have read and agree to the above consent clause.
  • The Fire Fighters Charity processes personal data in accordance with its Data Protection Policy. For full details of how the Charity processes your data, please see our Privacy Policy.
  • This field is for validation purposes and should be left unchanged.

Once you press ‘submit’ you will receive a confirmation email and a member of our team will contact you during our office hours: 9am – 5pm Monday – Friday.