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2. Youth Firesetter Information Request Form

   To obtain more information about the Youth Firesetter Program and/or to refer an individual to the program, please complete this form with parent/guardian information (no information regarding a child under 18 may be included on this form) and submit.  

   A Cosumnes Fire Department staff member will contact you within 2-5 business days.

4. First Name*

   Parent/guardian's first name

5. Last Name*

   Parent/guardian's first name

7. Address
9. City*
10. Zip Code
11. Phone Number*
12. Email Address
Leave This Blank:


14. 1. Receive an email copy of this form.
15. Email address

    This field is not part of the form submission.

16. Submit

* indicates a required field