Car Seat Program Infoline 614-645-7748
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Car Seat Program Infoline 614-645-7748
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Car Seat Appointment
May 14 @ 9:30 AM
-
12:30 PM
«
Private Appointment
Car Seat Appointment
»
2024 - Registrant Information
Appt. Date
*
Appt. Time
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
Appointment
*
I am scheduling this appointment for...
*
Myself
Someone Else
Your Name (First and Last)
*
Agency/Program/Relation
*
Email
*
Registrant Information
First Name
*
Last Name
*
Relation to Child
Mother
Father
Legal Guardian
Other
Relation to Child
Preferred Language
*
Select Your Language
English
Spanish
Haitian Creole
Nepali
Somali
French
Tigrinya
Arabic
Other
Preferred Language
Do you need an interpreter?
*
Yes
No
*7 day notice required for interpreter
Receiving WIC
*
Yes
No
Applied
Not Eligible
Receiving Medicaid
*
Yes
No
Applied
Not Eligible
Medicaid Provider
*
AmeriHealth Caritas
Anthem
Buckeye
CareSource
Humana Healthy Horizons
Molina
UnitedHealthcare Community Plan
I don't know
How did you hear about our program?
*
CelebrateONE
CPH Website
Doctor/Pediatrician
Friend/Family
My Baby & Me
Pamphlet
Police/Law Enforcement
Previous Class
Social Media/Search Engine
Vineyard
Walk In
WIC
Other
How did you hear about our program?
Please specify
Are you pregnant or expecting?
*
Yes
No
(If "Yes", don't forget to include this child below)
Expected Delivery Date
*
List All Children That Need Car Seats
Child
Has this child been born yet?
*
Yes
No
Child's First Name
*
Date of Birth
*
Child's Weight
*
0 - 39lbs
40lbs - 65lbs
Over 65lbs
plus
Add another child
minus
Remove this child
Household Information
Zip Code
*
Mobile/Cell Number
*
10-digit mobile number for text reminders
Email
*email provided will be used for Car Seat Program communications only
Comments / Special Requests
0
of 150 max words
Follow-up
Ethnicity
African American
Asian
Caucasian
Hispanic
Somali
Other
Ethnicity
Attendance
Attended
Did Not Attend
Cancelled
Payment
Amount Paid
Payment Type
Cash
Check
Check Number
*
If you are human, leave this field blank.
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Details
Date:
May 14
Time:
9:30 AM - 12:30 PM
Event Category:
General Appointment