Car seat Program Registration Form

Car seat Program Registration Form
Today's Date

Month Day Year
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

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

Area Code Phone Number
Email address *
What services are you requesting? *

I need a car seat I have a car seat but needs inspected I 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? *

Morning Afternoon Evening Anytime
Do you currently receive any type of government assistance? *
Will you be able to donate $25 to the Decatur Twp car seat program? *
Do you live within 10 miles of Decatur Township? *
If No, copy and paste the link to find a location near you. https://preventinjury.pediatrics.iu.edu/car-seat-help/child-safety-seat-inspection-stations/
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 website Indiana Injury Prevention/Car Seats Social media Other
Place answer if you chose other, in previous question. *
****For Official Use Only****

****For Official Use Only****