2. MUST BE 18 YEARS OLD TO FILL OUT FREE HELMET APPLICATION
4. 
   
6. Click Below or Fill out Online Application
   Application Form
8. Turn in application to Daniel Fernandez Recreation Center
10. 
    
12. Online Form
14. Name:*
16. 
    
18. Address:*
20. 
    
22. City:*
23. State:*
25. Zip:*
27. 
    
29. E-mail:*
31. 
    
33. In your own words, why are you requesting a free helmet?*
35. 
    
37. How many helmets are you requesting?*
    -- Select One --Blank123More than 3
38. What type of Helmet?*
    -- Select One --BlankBicycleSkateboardOther
40. 
    
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
48. 
    
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
52. 
    
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
56. 
    
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.
60. 
    
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