Appointment Scheduler

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.Appointment reminder emails will be sent out, please use an email you can check.

example@example.com

3

Phone Number* This field is required.

Text confirmations will be sent out the day before the event. You must respond by 10pm to keep your time slot

4

Child's Information* This field is required.Please list each child's age, estimated height and weight. If you are planning to receive a new seat an estimate is require for us to provide the proper seat. If you are expecting please tell us your estimated due date.

5

Are you in need of a new car seat?* This field is required.Seats are only available to qualifying families.

YESNO

6

Check the list below, do you qualify?* This field is required.As the parent or legal guardian of the child/children attending the car seat check, I certify the children receiving free car seats are CURRENTLY enrolled in one of the following programs: Referral from health department or other agency. Women, Infants, and Children (WIC) Partnership. Accountability. Training. Hope. (PATH) Cash Assistance Refugee Assistance Program Children's Special Health Care Services MI Child Head Start or Great Start Medicaid Children with Special Needs Fund Maternal Infant Health Provider (MIHP) services (or other home visitor program) Native American Outreach Program Family Independence Programs Social Security/Disability Bridge Card/food assistance Emergency replacement after fire, flood or crash (crash report or fire report required) Court referral or other court document Proof of child in foster care by foster parent or reunification plan

YESNO

7

Appointment* This field is required.Event will be held in Marquette, MI.