2025 Rainbow Car Seat Distribution Program/Ohio Buckles Buckeyes Program

2025 Rainbow Car Seat Distribution Program/Ohio Buckles Buckeyes Program
Has your child received a car seat/booster seat from UH Rainbow Babies & Children's Car Seat Program, Buckle Up for Life, Rainbow Connects or the Safe & Sound Program in the past 3 years?*

YESNO
Applicant Name (Parent/Caregiver)*

First NameLast Name
Do you live in Cuyahoga County*

YESNOOther
City*
Zip Code*
Phone Number - Be sure to check that the phone # you have provided is correct!*

Area CodePhone Number
May we contact you via SMS text message (message and data rates may apply)*

YESNO
How did you hear about the Rainbow Car Seat Distribution Program?*

211 - United WayCare SourceCleveland ClinicFriend/Family MemberMetroHealthMoms FirstRainbow ConnectsSocial WorkerUniversity Hospitals/Rainbow Babies & ChildrenWICOther
Email Address - re-enter for accuracy*

Confirmation Emailexample@example.com
Expectant parent?*

YESNO
If expecting, what trimester are you currently in?*

3rd trimester (months 7 9)Not currently expecting
Due Date - You must be in your 3rd Trimester to qualify for a car seat. (enter all zeros if not expecting). Example 05-24-2024.*

MonthDayYear
DUE DATE
Child's Name (If unborn, enter UNBORN)*
Child's age (if unborn, enter 0)*
Weight (if unborn, enter 0)*
Height in inches (if unborn, enter 0)*
Do you have another child that is in need of a car seat or booster seat? If so, please fill out table below. Please plan to bring their existing car seat/booster seat for evaluation.*

YESNO

Type a question

How many children typically travel in your vehicle?*

01234Other
* Program requirements can change at any time. Quantities of car seats/booster seats fluctuate and may not always be available.
You acknowledge that a virtual education session is necessary BEFORE you are able to pick up your car seat/booster seat and pick up is by appointment only.
Signature*
Type a question
Should be Empty: