Safe Kids | User Registration

Preferred Time*

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*

Child's Age*

*if child is 12-23 months, please select "1 year old"

Child's Weight*

Add another child Remove this child

Household Information

Zip Code*

Mobile/Cell Number*

for text reminders

Alternate Phone

Email

*email provided will be used for Car Seat Program communications only

Follow-up

Ethnicity

Attendance

Payment

Amount Paid

Payment Type

Cash

Check

Check Number*

User Registration

You selected: June 29, 2022 10AM - 2PM *COVID TESTS*

Registrant Information

List All Children That Need Car Seats

Household Information

Follow-up

Payment

You selected: June 29, 2022 10AM - 2PM COVID TESTS