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PARENTS & CAREGIVERS
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Youth Firesetter Prevention
& Intervention Program
Serving Tulare & Kings Counties
REFERRAL TO THE YOUTH FIRESETTER PREVENTION & INTERVENTION PROGRAM
After filling out the form below you may contact
the Program Manager at (559) 684-4365
Name of Minor:
*
Name of Parents/Guardians:
*
Date of Birth:
*
Month
Day
Year
Address:
Home Telephone:
*
Work Phone:
*
Cell Phone:
*
Age
*
Grade:
School:
Offense:
Code:
Suppression Costs Due: (If Applicable)
I agree to have (enter name below) participate in the Youth Firesetter Prevention & Intervention Program (YFP&I). In agreeing to this, I authorize the release of all information pertaining to my case between YFP&I and the referring agency listed above.
*
Signature of Minor:
*
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Signature of Parent/Legal Guardian
*
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Referred By (Name):
Title:
Agency:
Address
Contact Number:
Email:
If applicable please attach the Incident Report/Diagnosis/Photos:
Upload File
Submit
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