CHILD:

*  Last:		Required	* First:		Required	MI:
* Addr:		Required	* City:		Required
* State:		Required	* Zip:		Required

DOB:			Age:		Gender:		F M
Height:			Weight:		Hair:
Eyes:			Phone:		* School:			Required

PARENT/GUARDIAN:

* Last:		Required	* First:		Required	MI:
* Addr:		Required	* City:		Required
* State:		Required	*Zip:		Required
*Home Phone:		Required	Work Phone:
* Email:		Email Required	Invalid Email

PARENT/GUARDIAN 2

Last:		First:		MI:
Addr:		City:
State:		Zip:
Home Phone:		Work Phone:

NARRATIVE:

* Date of Report:		Required
* Incident #		Required
* Fire Officer/Firefighter Submitted Report		Required		* Denotes a Required Field

Please forward this form to Brent Smith. Parent/Guardian should be advised to contact

Brent Smith with the Juvenile Fire Setter Program at (319) 286-5200 or

b.smith@cedar-rapids.org to schedule an appointment.