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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.
Your name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Where did you hear about our programs?
Which language would you like to use at your appointment?
*
JCPH offers a free Lyft assistance program for clients without transportation. Do you need transportation to and from this appointment?
*
Yes
No
Which program are you applying for?
Car Seat
Safe Sleep
Both Car Seat and Safe Sleep
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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.
*
I am in need of a car seat
I already have a car seat - I just need a safety check
Other
Vehicle year, make, model
*
If you do not have a vehicle, write "no vehicle"
Child's name
*
If unborn, write "unborn"
Child's date of birth (or due date)
*
-
Month
-
Day
Year
Date
Child's weight
Pounds
Child's height
Feet/inches
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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
*
Less than high school diploma
High school diploma/GED
Some college
Associates degree
Bachelor's degree
Master's degree or higher
Marital status of mother/gestational parent
*
Single
Cohabitating
Married
Divorced
Widowed
Where do you plan to deliver your baby?
*
If not sure, write "unknown"
Race/ethnicity of mother/gestational parent
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White
Two or more races
Prefer not to answer
Other
Baby's race/ethnicity
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White
Two or more races
Prefer not to answer
Other
Age of mother/gestational parent
*
Household annual income
*
$0 - $5,000
$5,001 - $10,000
$10,001 - $15,000
$15,001 or more
Do you receive any of the following?
*
Medicaid
TANF
SSI/SSDI (disability)
SNAP/EBT (food stamps)
WIC
None
Other need-based public assistance
Do you smoke?
*
Yes
No
Does anyone in your household smoke?
*
Yes
No
Number of adults in your house
*
Number of children in your house
*
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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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