Town Of Buckeye Firesetter Prevention Program School Referral Form
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TOWN OF BUCKEYE
FIRESETTER PREVENTION PROGRAM
SCHOOL REFERRAL FORM
Date: __________
Referring School:
School District:
School Address:
City:
Zip:
Referrer’s Name:
Phone:
Fax:
Juvenile Information:
Name (Last, First, Middle):
D.O.B:
/
/
Sex: M F
Ethnicity: Caucasian
African American
Hispanic
Asian
Native American
Other
Age:
School:
Grade:
Home Address:
Phone:
-
-
Does child have A.D.D., A.D.H.D., or other mental health diagnosis?
Legal Guardian Information:
1.
Parent/Guardian Name:
Relationship:
Home Address:
Phone: H_____-_____-______
W _____-_____-______
2.
Parent/Guardian Name:
Relationship:
Home Address:
Phone: H_____-_____-______
W _____-_____-______
Fire Incident Information:
Location of Incident:
Date:
Incident #:
Was the parent / guardian notified? Y N
Was school counselor notified?
Y N
Name:
Were the others referred to the Firesetter Program? Y N
Was School Resource Officer notified? Y N
Name:
Was incident reported to the appropriate agency?
Y N
Agency Name:
Did either public safety agency respond?
Police Department
Fire Department
What was used to start the fire? (matches, lighter, etc)
How did the child obtain these items?
Was child alone or with others in the fire incident? (If not alone, list additional names)
How was the incident brought to attention at school?
What type of disciplinary action will the child receive?
Is mandatory attendance at a Firesetter Program part of the disciplinary action?
Signature of School Official Making Referral:
I am the parent/legal guardian of
and I give permission for
School to release this information for the Buckeye Fire Department, for enrolling my child in the Youth Firesetter Program.
________________________________
___________________
Parent / Legal Guardian Signature
Date
100 North Apache Road, Suite A • Buckeye, Arizona 85326 • P: (623) 349-6700 • F: (623) 349-6750
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