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

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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

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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?

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* 8. Would you like more information on the following items

Employment Assistance

Housing

Prenatal Care

Postpartum Care

Breastfeeding Information

Home Visitation Services

None of the above

Car Seat Class Registration

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

Question Title

* 1. Contact Information

Question Title

* 2. Are you expecting a child?

Question Title

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

Question Title

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

Question Title

* 5. Age of Child

Question Title

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

Question Title

* 7. How did you hear about this class?

Question Title

* 8. Would you like more information on the following items

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