Car Seat Class Registration

Children need a car seat that keeps them safe!
Every ride, every time!

Join us to receive general car seat and seat belt education and one-on-one help with car seat installation. You may qualify for a free car seat!

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* 1. Contact Information

Name

Address

City/Town

State/Province

County of Residence

Email Address

Phone Number

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* 2. Are you expecting a child?

Yes

No

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* 3. If so, when is your due date?

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* 4. Do you currently have a child in need of a car seat?

Yes

No

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* 5. Age of Child

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* 6. Do you receive Government Assistance? If yes, what form of assistance? (check all that applies)

TANF

Food Stamps

WIC

Housing Subsidy

Other (please specify)

None of the above

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* 7. How did you hear about this class?