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* Child's Name:

Child's Date of Birth:

* Child's Age:

School Attending:

School District:

* Parent/Guardian Name:

* Parent/Guardian Address:

* City: * Zip Code:

* Telephone Number:

Has the child been diagnosed with ADD/ADHD or other diagnosis?
Yes No

If Yes, for diagnosis, what diagnosis?

Did the fire department have to respond to the fire?
Yes No

What did the child use to set the fire?

Was the child alone or with others when he/she set the fire?
Yes No

Does the child have a history of playing with matches or lighters?
Yes No

Has the child set previous fires?
Yes No

Do you have working smoke alarms in your residence?
Yes No

Does anyone smoke in the residence?
Yes No

Give a brief explanation of the firesetting event:

* required fields

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