Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Date:MM/DD/YYYYParents/Guardians Name: *FirstLastStreet Address: *City: *Telephone #: *Email Address:Child's Name:FirstLastChild's Date of Birth/Due Date:MM/DD/YYYYChild'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?YesNoDo you own a car?YesNoVehicle Year, Make, Model:Are there workable seatbelts in the car?YesNoIf yes, how many?Please enter a number from 1 to 9How did you hear about this program?Submit
