Car Seat Program Infoline 614-645-7748
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Car Seat Program Infoline 614-645-7748
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10:00 AM
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02:00 PM
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Agency/Program/Relation
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Email
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Registrant Information
First Name
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Last Name
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Relation to Child
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Relation to Child
Preferred Language
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Select Your Language
English
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Preferred Language
Do you need an interpreter?
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*7 day notice required for interpreter
Receiving WIC
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Applied
Not Eligible
Receiving Medicaid
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Yes
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Applied
Not Eligible
Medicaid Provider
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AmeriHealth Caritas
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Molina
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How did you hear about our program?
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CelebrateONE
CPH Website
Doctor/Pediatrician
Friend/Family
My Baby & Me
Pamphlet
Police/Law Enforcement
Previous Class
Social Media/Search Engine
Vineyard
Walk In
WIC
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Are you pregnant or expecting?
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No
(If "Yes", don't forget to include this child below)
Expected Delivery Date
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List All Children That Need Car Seats
Child
Has this child been born yet?
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Yes
No
Child's First Name
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Date of Birth
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Child's Weight
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0 - 39lbs
40lbs - 65lbs
Over 65lbs
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Add another child
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Remove this child
Household Information
Zip Code
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Mobile/Cell Number
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+1
10-digit mobile number for text reminders
Email
*email provided will be used for Car Seat Program communications only
Comments / Special Requests
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Ethnicity
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