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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!
*
1.
Contact Information
(Required.)
Name
Address
City/Town
State/Province
County of Residence
Email Address
Phone Number
*
2.
Are you expecting a child?
(Required.)
Yes
No
3.
If so, when is your due date?
*
4.
Do you currently have a child in need of a car seat?
(Required.)
Yes
No
5.
Age of Child
*
6.
Do you receive Government Assistance? If yes, what form of assistance? (check all that applies)
(Required.)
TANF
Food Stamps
WIC
Housing Subsidy
Other (please specify)
None of the above
7.
How did you hear about this class?
*
8.
Would you like more information on the following items
(Required.)
Employment Assistance
Housing
Prenatal Care
Postpartum Care
Breastfeeding Information
Home Visitation Services
None of the above
