Safe Kids Sarpy/Cass Car Seat and Installation Assistance

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: To provide as much flexibility as possible for parents and caregivers, our appointment days, times, and locations may vary. We will contact you to schedule a specific date and time based on our availability and your calendar. We appreciate your patience!
If you have any trouble submitting this survey please email rdysico@sarpycasshealth.com
Thank you and remember to buckle up!

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

First and last name:

Phone number:

Email address:

County of residence: (e.g. Sarpy, Douglas, Cass)

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

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

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

Yes

I am in need of a grant funded car seat, but I do NOT receive state or federal aid