Car Seat Support Request Intake Form

Car Seat Support Request Intake Form

*Please allow at least 48 hours for a car seat technician to contact you.
Name of caregiver:*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Make and Model of the vehicle child(ren) travel in:*
Does this vehicle belong to you?*

YesNo
Child 1
Age:
Height:
Weight:
Currently in a child restraint?

YesNo
Brand and Make of current car seat:
Does child need a seat?

YesNo
Does child have any special needs to be considered: If yes, please explain:
Child 2
Age:
Height:
Weight:
Currently in a child restraint?

YesNo
Brand and Make of current car seat:
Does child need a seat?

YesNo
Does child have any special needs to be considered: If yes, please explain:
Child 3
Age:
Height:
Weight:
Currently in a child restraint?

YesNo
Brand and Make of current car seat:
Does child need a seat?

YesNo
Does child have any special needs to be considered: If yes, please explain:
*LCPH partners with Healthy Mother's Healthy Baby and other organizations to provide car seats for families that may not have the means to purchase one themselves. Availability is dependant on funding and is not guaranteed. If available, please allow at least two weeks for delivery.
Should be Empty: