Car Seat Support Request Intake Form

Car Seat Support Request Intake Form

*Please allow at least 72 business hours for a car seat technician to contact you.
*LCPH partners with Healthy Mother's Healthy Baby and other organizations to provide car seats for families that do 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. Please note: one car seat per family and car seats are only available for children under 3.
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?
Who referred you to our Safe Seat program:
Are you a current client of:
Child
Age:
Height:
Weight:
Currently in a child restraint?
Brand and Make of current car seat:
Does child need a seat?
Does child have any special needs to be considered: If yes, please explain:
Should be Empty: