CHILD:
*
Last:
*
First:
MI:
*
Addr:
*
City:
*
State:
*
Zip:
DOB:
Age:
Gender:
F
M
Height:
Weight:
Hair:
Eyes:
Phone:
*
School:
PARENT/GUARDIAN:
*
Last:
*
First:
MI:
*
Addr:
*
City:
*
State:
*
Zip:
*
Home Phone:
Work Phone:
*
Email:
PARENT/GUARDIAN 2
Last:
First:
MI:
Addr:
City:
State:
Zip:
Home Phone:
Work Phone:
NARRATIVE:
*
Date of Report:
*
Incident #
*
Fire Officer/Firefighter Submitted Report
* 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.