Private Appointment
2025-10-09 09:00 - 14:00 (America/New_York)
2024 - Registrant Information

Appt. Date
*

Appt. Time

6:00 AM6:30 AM7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM8:30 PM9:00 PM9:30 PM10:00 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
*

MotherFatherLegal GuardianOther
Relation to Child

Preferred Language
*

Select Your LanguageEnglishSpanishHaitian CreoleNepaliSomaliFrenchTigrinyaArabicOther
Preferred Language

Do you need an interpreter?
*

Yes

No

*7 day notice required for interpreter

Receiving WIC
*

YesNoAppliedIncome EligibleNot Eligible

Receiving Medicaid
*

YesNoAppliedIncome EligibleNot Eligible

Medicaid Provider
*

AmeriHealth CaritasAnthemBuckeyeCareSourceHumana Healthy HorizonsMolinaUnitedHealthcare Community PlanI don't know

How did you hear about our program?
*

CelebrateONECPH WebsiteDoctor/PediatricianFriend/FamilyMy Baby & MePamphletPolice/Law EnforcementPrevious ClassSocial Media/Search EngineVineyardWalk InWICOther
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 Under the Age of 8 WITHOUT a Car Seat or Booster Seat
By Ohio law, all children under the age of 8 years old must ride in a car seat or booster seat

Child

Has this child been born yet?
*

Yes

No

Child's First Name
*

Date of Birth
*

Child's Weight
*

0 - 39lbs40lbs - 65lbsOver 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 AmericanAsianCaucasianHispanicSomaliOther
Ethnicity

Attendance

AttendedDid Not AttendDeclined Car SeatCancelled

Date of Manufacture

Seat Type

RFOConvertibleConvertible - RFConvertible - FFHighbackBackless

Date of Manufacture

plus

Add

minus

Remove

Payment

Amount Paid

Payment Type

Cash

Check

Check Number
*

Consents

Consent Statements
*

I understand I have to pay a fee for my car seat(s) and/or booster seat(s) at the time of my appointment.

Appointment Consent
*

I understand the appointment will take 20 – 30 minutes to cover the full education of the car seat and its installation.

If you are human, leave this field blank.

Car Seat Appointment
2025-10-09 12:00 - 14:00
