Car Seat Program Registration Form

Car seat Program Registration Form
Today's Date

MonthDay Year
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 and search your counties 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 Name Last Name
Address*

Street Address

Street Address Line 2

City State / Province

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

Area Code Phone 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?*
Will you be able to donate $25 to the Decatur Twp car seat program? *
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.

Car seat Program Registration Form