Child Safety Seat Application

If you are a family in need of a child safety car seat, please submit the following application. These car seats were purchased with funds donated by Louisiana's Sonic Drive-ins to go to families in need throughout the state. Car seats will be assigned to families approved on a first-come, first-serve basis. Please limit one seat per child. If you have more than one child needing a car seat, please submit the application for each child.

The deadline to submit the application is Friday, September 28, 2018.
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First Name
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Last Name
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Email
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Telephone
  
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Child's First Name:
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Child's Last Name:
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Child's Age:
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Child's Weight:
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Child's Height:
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Vehicle Year:
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Vehicle Make:
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Vehicle Model:
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City of Residence:
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Which location is nearest you for seat distribution?
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Do you currently have a child safety seat (car seat) for your child?
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Can you afford to purchase a child safety seat (car seat) for your child?
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Are you an LCMC Health employee?
Additional Comments
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Please check the box to acknowledge you have read the following terms.

Our Partners

 

The Louisiana State University Health Sciences Center New Orleans has teaching, research, and health care functions state-wide, through its six professional schools and twelve Centers of Excellence, as well as the more than one hundred hospitals and other health science related institutions with which they maintain affiliations.

 

The second-oldest medical school in the Deep South and the 15th oldest medical school in the United States, Tulane School of Medicine is equipping the next generation of medical professionals with the tools to succeed in a rapidly changing world and shape the future of health care.