CHILD SAFETY SEAT APPLICATION

The Show Low Police Department has a limited number of child safety seats available for people who cannot afford to purchase one. Distribution of these seats is based upon the individual's need, following the guidelines of A.R.S. 28-907M1 and 36-2901.01. Basically, if you qualify for food stamps, case assistance or AHCCES, you are eligible for this program. If eligible, use this form to apply for a free child safety seat.

Please fill out the following information.  If selected to receive a child seat, you will be required to meet with a child seat technician for a short safety course.

Full Name: 
Date of Birth: 

Address: 

Daytime Phone Number: 
    Cell Phone: 
Child's Full Name: 

Child's Date of Birth: 

Please provide a short explanation of how you qualify for this program, i.e., limited or no income, qualification for state benefits, etc.: