Car Seat Program Registration Form

Car seat Program Registration Form
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Please read before filling out this form.

Stop filling out this form if you do not live in Decatur Township, Marion County, Indiana, 46221, or a surrounding county.

Please click on the link below to search the county you live in for car seat clinic/inspection site closest to you.

https://preventinjury.pediatrics.iu.edu/car-seat-help/child-safety-seat-inspection-stations/list-of-child-safety-seat/
I agree that I have read the above and searched for a car seat site located closest to my home?*
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip Code*
What county do you live in?*
Phone Number*

Area CodePhone Number
Email address*
What services are you requesting?*

I need a car seatI have a car seat but needs inspectedI have a Project Love Voucher
What are the ages of the children?*
If not born yet when is your due date?*
What is the best time to reach you?*

MorningAfternoonEveningAnytime
Do you currently receive any type of government assistance?*
Have you previously received a car-seat from the Indiana Car-seat Program?*
What are you currently using for a car seat?*
How did you hear about our program?*

Decatur Twp Fire websiteIndiana Injury Prevention/Car SeatsSocial mediaOther
Place answer if you chose other, in previous question.
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Car seat Program Registration Form