City of Winnipeg
Fire Paramedic Service
PUBLIC EDUCATION
FPS-FP-Publiced@winnipeg.ca
YOUTH FIRE STOP PROGRAM - REFERRAL FORM
(17 years and under)
Referring Agency:
*
Referring Person:
*
Referring Person Contact:
*
Are you the Legal guardian?
*
Yes
No
If No, List Relation:
All Youth Fire Stop referrals must be made with the legal guardian's written consent.
A consent form must be signed for us to meet with you and your child.
Date/Time Of Incident:
*
Dollar Loss if any:
*
$
Ignition Source (lighter,matches,other):
*
Items Ignited:
*
Did Fire Department attend incident?
*
Yes
No
Child's First Name:
*
Last Name:
*
Gender :
Date of Birth:
*
Parent/Guardian:
*
Address:
*
Phone:
Email Address:
*
Confirm Email Address:
*
School Name:
*
Grade:
*
Comment on Incident:
% = the size of the detail information based on the maximum capacity for this email form. Details may not exceed 100%.
For further information, contact the Public Education branch at 204-986-5449 or email at FPS-PubEd-YFS@winnipeg.ca.
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