Car Seat Event Request Form

Car Seat Request Form
Thanks to generous funding from Volvo Group, we are able to provide car seats for families in need.

To qualify for a car seat, you must:

1.     Be a resident of Guilford County,

2.     Be the parent or primary caregiver,

3.     Enrolled in a financial assistance program like Medicaid or otherwise cannot afford a car seat.

One seat per child.

If you are currently pregnant, you must be in your 3rd trimester to receive a seat. We do not carry rear-facing only car seats for children. For infants, please select the Evenflo Titan 65 convertible car seat.

Please fill out the following information to sign up for a car seat event where you will receive your car seat(s). You will be required to learn how to use the car seat at the event. This will take approximately 15-20 minutes per seat.

These are the only available events. If you have questions, please contact Leigha Jordan at leigha.jordan@conehealth.com.
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address
example@example.com
Address*

Street Address

Street Address 2

CityState / Province

Postal / Zip Code
Which event will you come to?*
Car Seats*
prevnext( X )
Evenflo Titan 65 Convertible Car SeatEvenflo Titan 65 convertible car seat keeps your child safely rear-facing from 5 lbs. to 40 lbs., and forward-facing from 22 lbs. to 65 lbs. Choose this option for children under 30 lbs. and/or less than 2 years old.
$ Free Quantity



Cosco Finale 2-in-1 Booster Car SeatProtects children forward-facing with a safety harness from 30 lbs. to 65 lbs. and in booster mode from 40 lbs. to 100 lbs. Choose this seat for children who are at least 2 years old and at least 30 lbs.
$ Free Quantity



Evenflo Go Time No Back BoosterBoosts children up to fit the seat belt. Choose for children at least 4 years old and 40 lbs. to 110 lbs.
$ Free Quantity



Total

$0.00
What agency referred you?*
Referral Agent Name

First NameLast Name
Referral Agent Email
example@example.com
Should be Empty:

Car Seat Request Form