Car Seat Program Application

Car Seat Application
Applicant Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Phone Number
Relationship to Child
Household Information
Number of Adults in Household
Number of Children in Household
Monthly Gross Income (before taxes)
Do you receive any of the following? Select all that apply.

MedicaidWICSSITANFFood StampsSection 8 Housing
Child Information

If child is unborn, please put due date instead of birth date and '0' in height and weight fields.
Birth Date

MonthDayYear
Height (in)*
Weight (lb)*
Current Car Seat Information

Please enter information about your child's current car seat. Information about the car set you are currently using can be found on the car seat usually as a sticker on the bottom, back, or side of the seat or in the owner's manual. If you do not currently have a car seat, please enter 'unknown' in these fields.
Car Seat Manufacturer
Car Seat Model
Expiration Date
Car Information

Please enter the information of the car the car seat will be installed in.
Make*
Model*
Year*
Signature

Clear
Should be Empty:

Car Seat Application