DRUPLA FORM TEST PAGE Firelighting Consequence Awareness Program (Fire-CAP) Referral Form

Fire-CAP Referral Form

Use this form to refer a child/young person to the Fire-CAP program. You will need to provide your own contact details, details for the parents/guardian and the child/young person.


Part 1: Referrer details

Provide your own contact details here. Details for the parent and child are provided later in this form.

Agency(Required)
Has the primary carer given permission for this referral?(Required)
Is the referral based on a Police or Court Order?(Required)
How did you hear about the program?(Required)

Part 2: Primary carer details

Provide the details of the parent/guardian of the child/young person you are referring. You only need to provide the details of one of the parents.

Relationship to child/young person(Required)

eg. 100 Empress Rd, Surrey Hills, 3127

Is the family from a culturally & linguistically diverse background?

Part 3: Child/young person details

Child/young person sex(Required)
Child/young person pronouns(Required)
Child/young person date of birth

Leave blank if unknown.

Provide approximate age if exact age is unknown

Is the child/young person of Aboriginal or Torres Strait Islander origin?
Reason for referral(Required)

Please provide a brief description about the firelighting/fire risk behaviour i.e. where, when, alone or with others, ignition source, did the fire brigade or other emergency services attend, etc.

Privacy statement(Required)

Fire Rescue Victoria (FRV) collects the information that you provide with this referral/enquiry form. If you need to use an alternative mechanism to the online form, please contact the Fire-CAP state coordinator on 1300 367 617 or e-mail firecapoffice@frv.vic.gov.au. The information that you provide is used to respond to your enquiry and may result in the referred person becoming involved in the Fire-CAP. FRV is bound by the Privacy and Data Protection Act 2014 (Vic) and is required to adhere to the Information Privacy Principles which set out the minimum standards for the handling of personal information in the Victorian public sector. FRV is committed to protecting your privacy and will collect, hold, use and disclose your personal information accordingly. You can request access to, and corrections of, any personal information provided in this form. Requests for access or correction should be sent to FRV's Privacy team. FRV is using the services of Drupal to administer this form. The information that you provide is stored in our Drupal content management system and Amazon Web Services servers. For more information on FRV’s handling of any personal information, please refer to Fire Rescue Victoria’s Privacy Statement. If you do not provide all or part of the information requested, FRV may not be able to contact you regarding your enquiry.

Updated