Car Seat & Safe Sleep Program Form
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  • Car Seat & Safe Sleep Program Form

    Please use this form to register for a car seat safety check, apply for a car seat, and/or apply for a Safe Sleep class (crib). Receipt of a free car seat or crib are subject to eligibility and inventory. All responses are completely confidential and will not be discussed with anyone outside of Jackson County Public Health.

  • This program can only serve residents of Eastern Jackson County OUTSIDE of Kansas City or Independence.

    For KC and Independence residents, please contact your city's health department or Safe Kids for car seat assistance.
  • Format: (000) 000-0000.
  • JCPH offers a free Lyft assistance program for clients without transportation. Do you need transportation to and from this appointment?*
  • Which program are you applying for?

  • What To Expect: Car Seat Program

    After submitting this form, a staff member will contact you within one business day to review your information. If the application is accepted, we will schedule a 30-minute education and installation appointment, during which a Certified Child Passenger Safety Technician will work with you to ensure your child's safety and comfort in the car seat. Each child may receive up to one car seat every two years.
  • Check the appropriate option.*
  • Child's date of birth (or due date)*
     - -

  • What To Expect: Safe Sleep Program

    After submitting this form, a staff member will contact you within one business day to review your information. If the application is accepted, we will schedule a 1-hour Safe Sleep class at our office. All caregivers are welcome to attend the appointment. The class will go through Safe Sleep guidelines, answer any questions you have, and practice setting up the crib (Pack N Play). Families may receive up to one crib every two years (two cribs for twins).
  • Education level of mother/gestational parent*
  • Marital status of mother/gestational parent*
  • Race/ethnicity of mother/gestational parent*
  • Baby's race/ethnicity*
  • Household annual income*
  • Do you receive any of the following?*
  • Do you smoke?*
  • Does anyone in your household smoke?*

  • One more step!

    After you click Submit, you will be redirected to a Social Needs Assessment form. We use this form to help connect community members with resources to help with things like housing, food, mental health, and substance use. If you have any questions, please call us at 816-404-6493 or email healthpromotions@uhkc.org.
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