Safe Kids | User Registration

I am scheduling this appointment for...

Myself

Someone Else

Preferred Time*

Your Name (First and Last)

Agency/Program/Relation

Email

Registrant Information

First Name*

Last Name*

Relation to ChildRelation to Child

Preferred Language*Preferred Language

Do you need an interpreter?*

Yes

No

*7 day notice required for interpreter

Receiving WIC*

Receiving Medicaid*

Medicaid Provider*

How did you hear about our program?*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*

Add another child Remove this child

Household Information

Zip Code*

Mobile/Cell Number*

+1

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

Attendance

Payment

Amount Paid

Payment Type

Cash

Check

Check Number*

User Registration

You selected: August%2023,%202022%2010AM%20-%202PM%20*Mere%20at%20KIM*

Registrant Information

List All Children That Need Car Seats

Household Information

Follow-up

Payment

You selected: August%2023,%202022%2010AM%20-%202PM%20Mere%20at%20KIM