The information you provide on the next few pages will help our Child Passenger Safety technicians schedule your car seat check for the appropriate amount of time.  The more complete your answers, the better we are able to estimate timing. You may want to gather some information before beginning:  Height and weight of the child, as well as model number and manufactured date of the seat (if applicable).  The survey should not take longer than 10-15 minutes if you have collected this information in advance.  
 
We value your privacy and will not share or sell any of your information.  
After we have reviewed your responses we will call and/or email to schedule a specific day and time for the installation.  If you have any difficulty completing the survey you may call us at 402-537-6976 or 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 

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* 2. What is the make, model, and year of your VEHICLE?

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* 3. Do you have more than one vehicle you would like us to check?

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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

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* 5. As part of our continued efforts to provide services and resources to our community's service members/veterans and the families that support them, we would appreciate your response below.
Please choose the statement that best describes you...

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