2. El Cerrito and Kensington residents can complete this form to obtain your free Vial of Life kit from the El Cerrito-Kensington Fire Department. For more information, please call 215-4450.
   
4. First Name:
5. Last Name:
7. Street Address:
9. City:
10. State:
11. Zipcode:
13. Number of Kits Requested:
    -- Select One --123
Leave This Blank:


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

    This field is not part of the form submission.

17. Submit Submit and Print

* indicates a required field