Free Helmet Application Form

2. MUST BE 18 YEARS OLD TO FILL OUT FREE HELMET APPLICATION

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6. Click Below or Fill out Online Application
   Application Form

8. Turn in application to Daniel Fernandez Recreation Center

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12. Online Form

14. Name:*

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18. Address:*

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22. City:*

23. State:*

25. Zip:*

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29. E-mail:*

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33. In your own words, why are you requesting a free helmet?*

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37. How many helmets are you requesting?*
    -- Select One --Blank123More than 3

38. What type of Helmet?*
    -- Select One --BlankBicycleSkateboardOther

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42. Names and Ages of Minors (youth):*

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46. If request is granted, would you use free helmet on public sidewalks, roads, parks, and or skate park?*

    1. Yes
    2. No
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50. Did you know it is law that anyone under the age of 18 (minor) must wear protective head gear on public sidewalks, roads, parks, and or Skate Park?*

    1. Yes
    2. No
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54. Do you understand that you can be cited for not wearing a helmet by police or park rangers on public sidewalks, roads, parks, and or skate park?*

    1. Yes
    2. No
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58. You will be contacted within 48 hours to review your application and schedule a fitting appointment.

    The Los Lunas Police Department and Los Lunas Parks & Recreation Thanks You for supporting child safety.

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Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field