Ohio Buckles Buckeyes Car Seat Application

Ohio Buckles Buckeyes Car Seat Application

Please submit a separate application for each child/seat
Parent/Guardian Name*

First NameLast Name
Relationship to Child*
E-mail
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County of Residence*
You MUST live in Athens County, Ohio to receive a free car seat.
Phone Number*

Area CodePhone Number
Name of Child to Receive Car Seat*
Child's Birth Date*

MonthDayYear
Child's Age*
Weight
Height
Is this child receiving WIC Benefits?
Please answer the following questions completely.

Failure to do so may result in ineligibility.
Name of Everyone in Household
Last, First
DOB
Sex
Employer
Gross Amount
Last, First
DOB
Sex
Employer
Gross Amount
Last, First
DOB
Sex
Employer
Gross Amount
Last, First
DOB
Sex
Employer
Gross Amount
Last, First
DOB
Sex
Employer
Gross Amount
What kind of car will the seat be installed in?
Make
Model
Year
Does your car have working seatbelts?
Have you ever received a car seat or car seat education from this program before?
Do you or anybody else smoke in the car when this child is present?
By signing this application, I agree to give documentation and verification of the information in this application. I give my consent to Athens - Hocking - Perry Community Action to make whatever contacts are necessary to determine and verify my eligibility. I affirm under penalty of perjury that the above information on this application is true and complete to the best of my knowledge.*

I Agree
Should be Empty: