CAR SEAT CHECK REQUEST FORM

CAR SEAT CHECK REQUEST FORM
Car Seat Distribution Information
Thanks to generous funding from Volvo Group, we are able to provide car seats for families in need.

Qualifications

To qualify for a car seat, you must:
- Be a resident of Guilford County,
- Be the parent or primary caregiver,
- Enrolled in a financial assistance program like Medicaid or otherwise cannot afford a car seat.
Obtaining a Car Seat
1. One seat per child, not per vehicle. There is a three-seat maximum.
2. The type of car seat (Convertible, 2-in-1 Booster, or No-Back Booster) will be assigned based on the child's age, weight, and height.
3. Expectant mothers must be in their third trimester to be eligible for a seat.
4. Only a parent, legal guardian, or referring agency may receive the car seat(s) at the event.
5. At least one parent or legal guardian listed on this form must be present with a valid photo ID to collect the seat, unless an authorized referral agency representative is obtaining the seat(s) on their behalf.
6. You will be required to learn how to use the car seat at the event. This will take approximately 15-20 minutes per seat.
7. Families can receive car seat(s) once every 12 months. You will become eligible for another seat one year after your last distribution date.
8. We do not carry rear-facing only car seats for children.
Please fill out the following information to sign up for a car seat event where you will receive your car seat(s).

If you have questions or special circumstances in which you need additional car seats, please contact Leigha Jordan at leigha.jordan@conehealth.com.
I have read the information above and agree that I meet the qualifications and understand the requirements to obtain a car seat, and will be required to learn how to use the car seat.
Car Seat Check Events

Families can receive car seat(s) once every 12 months. You will become eligible for another seat one year after your last distribution date.
Select an Event*
Appointment*
Parent/Legal Guardian Contact Information

At least one parent or legal guardian listed on this form must be present with a valid photo ID to collect the seat, unless an authorized referral agency representative is obtaining the seat(s) on their behalf.
Parent/Legal Guardian #1*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Legal Guardian #2

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child Demographic Information

List up to three children. List name(s), age, weight, and height.
Child #1*

First NameLast Name
Age*
Weight (lbs) *
If an expectant mother, list zero.
Height (in)*
If an expectant mother, list zero.
Child #2

First NameLast Name
Age
Weight (lbs)
If an expectant mother, list zero.
Height (in)
If an expectant mother, list zero.
Child #3

First NameLast Name
Age
Weight (lbs)
If an expectant mother, list zero.
Height (in)
If an expectant mother, list zero.
Referral Information
What agency referred you?*
If other, list agency name.
Referral Agent Name

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

CAR SEAT CHECK REQUEST FORM

Car Seat Distribution Information

Car Seat Check Events

Parent/Legal Guardian Contact Information

Child Demographic Information

Referral Information