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Car Seat Appointment Request Form
Tuesday, November 11, 2025: 3pm-5:30pm @ Keizer Fire Station
Car seat checks are free. Car seats are available for a co-pay for those who are income eligible.
The cost of the copay will be determined by the type of seat needed. The highest copay cost is $30/seat. Please only choose one appointment slot; no matter how many children you have, they will all be seen at the same time.
What is your preferred language?
English
Spanish
Other
Do you currently own a car seat that you would like checked for correct installation?
Yes
No
Do you need a new car seat? New car seats are available for a co-pay for those who are income eligible.
Yes
No
Are you pregnant?
Yes
No
How many children currently ride in your vehicle on a regular basis?
0 (I'm pregnant)
1
2
3
4
5
More than 5
Due Date
-
Month
-
Day
Year
Date
What are the ages of children who ride in your car? Please check all that apply.
0-1 year old
1-2 years old
2-3 years old
3-4 years old
4-5 years old
5-6 years old
6-7 years old
7-8 years old
8-9 years old
9-10 years old
10+ years old
Income eligibility to receive a car seat for a co-pay.
My child or I receive WIC (provide eligibility letter)
I receive TANF for myself or my children (provide verification via portal or letter)
I receive SNAP benefits for myself or my children (provide verification via portal or letter)
I am income eligible, but do not receive benefits from WIC, TANF or SNAP (we will call you to discuss what proof/verification is necessary)
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email
example@example.com
Zip code you reside in
*
Appointment: Please only choose one appointment slot; no matter how many children you have, they will all be seen at the same time.
If there are no more slots available for this clinic, would you like to be placed on a waitlist?
Yes
No
How did you hear about the car seat clinic?
Is there something else we should know or that you have questions about before the clinic?
Save
Submit
Should be Empty: