Child Passenger Safety Program Application Date: Month Day Year Parents/Guardians Name:(Required) First Last Address:(Required) Street Address City Telephone #:(Required)Email Address: Child's Name: First Last Child's Date of Birth/Due Date: Month Day Year Child's Present Weight and Height:Has this child received a car seat from this program in the past?NoYesNot sureNumber in family:Do you qualify for WIC &/or Medicaid?YesNoIf not, monthly income $:Do you own a car?YesNoIf not, who owns the vehicle you will be using?What is his/her relationship to you?Vehicle Year, Make, Model:Are there workable seatbelts in the car?YesNoIf yes, how many?Please enter a number from 1 to 9.How did you hear about this program? Δ
