The information you provide on this survey will help our Child Passenger Safety technicians schedule your car seat check appointment.  By understanding your needs and unique situation, we will be better prepared to help answer all of your questions.  
We value your privacy, and will not share or sell any of your information.  

Please note: The fourth Thursday of the month is our preferred installation appointment day.   However, appointments may be scheduled directly with one of our child passenger safety technicians.  We will contact you to schedule a specific date and time based on our availability and your calendar. 
Also, if you have any trouble submitting this survey please email rdysico@sarpycasshealth.com
Thank you and remember to buckle up!

Question Title

* 1. Please enter the best contact information for us to use when scheduling appointments

Question Title

* 2. How did you hear about our car seat program?

Question Title

* 3. Have you, or have any of your immediate family members, ever served in the military?

Question Title

* 4. We offer installation appointments on the fourth Thursday of the month between 8:30 a.m. and 3 p.m.  Occasionally, our technicians are available on alternate days and times.  We will do our best to consider your calendar when scheduling an appointment.  Please complete the ranking below to help us better understand your preferred days and times.  We do not schedule installations on Federal holidays, Saturdays, or Sundays.  Thank you!

Question Title

* 5. If you are never available Monday - Friday between 8:30 a.m and 3 p.m., please indicate your preferred day & time.  As we schedule our future inspection station dates & times, we will consider your responses to help guide our calendar.  Thank you!

Question Title

* 6. Do you receive state or federal aid and are in need of a car seat?  Some examples are Medicaid, WIC, SNAP

T