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Safe Haven Materials Request

The form below is for Safe Haven facilities in the state of Louisiana to request materials. If you are a Safe Haven facility in Louisiana, please fill out the form below and you will receive your items in 7 to 10 days.

These items, along with the Medical and Genetic History Form, are also available for downloading and printing via http://www.dcfs.louisiana.gov/index.cfm?md=pagebuilder&tmp=home&pid=223

Bold indicates required fields

E-Mail Address
Secondary Email Address
Name of Facility
Contact Person
Type of Faciliity Child Advocacy Center
Crisis Pregnancy Center
Emergency Medical Service Providers
Fire Station
Hosptial
Medical Clinic
Police Station
Public Health Unit
Mailing Address
City
State
Zip Code
Contact Phone Number
Items Requested Brochure
Poster
Safe Haven Card
Window Decal
Safe Haven Logo (Sent by E-mail)

Decals say "Safe Haven Site"
Number Requested of Each
Brochure
Poster
Safe Haven Card
Window Decal