Car Seat Program Infoline 614-645-7748
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Car Seat Program Infoline 614-645-7748
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User Registration
You selected: June 29, 2022 10AM - 2PM *COVID TESTS*
Registrant Information
Preferred Time
*
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
01:00 PM
01:30 PM
02:00 PM
Registrant Information
First Name
*
Last Name
*
Relation to Child
Mother
Father
Grandparent
Aunt
Uncle
Guardian
Other
Relation to Child
Preferred Language
*
Select Your Language
English
Spanish
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
Buckeye
CareSource
Molina
Paramount Advantage
United Healthcare
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
TV/Radio
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
*
Child's Age
*
Less than 12 months
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 years old
*if child is 12-23 months, please select "1 year old"
Child's Weight
*
0 - 39lbs
40lbs - 65lbs
Over 65lbs
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
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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