Fireproof Interest Form

Fireproof is a Wellness Program offered to fire personnel by The 100 Club of Arizona

Fireproof is offered to Public Safety Agencies statewide as part of The 100 Club of Arizona's Peer100 Program and is generously sponsored by The Bob & Renee Parsons Foundation.

If you have additional questions, please feel free to contact:

Rainee Crabtree, Programs Manager

rainee@100club.org

602-485-0100.

For additional information about 100 Club, please visit www.100club.org.

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* 1. Department Information

Department/Agency Name

Mailing Address

Mailing Address 2

City/Town

State/Province

ZIP/Postal Code

Main Phone Number

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* 2. Fire Chief

Name

Email Address

Phone Number

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* 3. Assistant Chief or Second in Command

Name

Email Address

Phone Number

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* 4. Individual Completing this Survey

Name & Title

Email Address

Phone Number

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* 5. Fireproof

As you know, first responders are regularly faced with critical incidents and repeated exposure to traumatic situations. These have profound impact on their mental health and wellness.

To support them, the 100 Club offers critical resources through the Fireproof Mobile App Preview Video.

Fireproof is a confidential, anonymous resource that provides first responders and their families with mental health and wellness initiatives to ensure they have support through critical times of need.

The Fireproof App is available for download and features cutting edge, confidential access to both mental and physical wellness resources. Through the mobile app, agencies across Arizona will have the ability to customize resources available to their personnel as well as access training materials to support seamless implementation.

If you are interested in participating in the Fireproof Wellness Mobile App please indicate below

Yes, sign us up!

No, we are not interested at this time

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* 6. If you answered yes to the above question, please provide the contact information below.

Department or Agency Wellness Coordinator Name

Department or Agency Wellness Coordinator Email

Department or Agency Wellness Coordinator Contact Number

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* 7. Please upload your badge, patch or logo.

PNG, JPG, JPEG file types only.

Choose File

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* 8. Please send me updates on the release of the Fireproof MobileApp

Yes

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* 9. The 100 Club of Arizona

The 100 Club of Arizona provides many programs to support Arizona’s first responders through financial assistance, training and safety equipment. If you would you like additional information or a 100 Club representative to provide an overview of 100 Club programs, please complete the information below.

Yes, please contact me to schedule a 100 Club of Arizona Program overview at my Department or Agency

Yes, please email me information about The 100 Club of Arizona programs

No, we are not interested at this time