Online Car Seat Registration Form - Kern County Public Health

Are you a Kern County resident?*

Proof of residency will be required.

Yes
No

Name*

First Last

Date of Birth*

Please enter your address below*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email

Preferred Language

Race

Select all that apply

Asian
Black/African
White/Caucasian
Hispanic/Latino
Native American
Pacific Islander
Other

Expectant Mother

Yes
No

Due Date (if expecting)

Relationship to Child

Child's Name

First Last

Gender (Child)

Child's Date of Birth

Weight (Child)

Height (Child)

Vehicle Year

YYYY

Vehicle Make and Model

Do you have the vehicle owner manual?*

Yes
No

Do the seat belts in the car function?*

Yes
No

What type of car seat do you currently have for your child?*

Infant Seat 0-9 mos.
Convertible Seat 0-3yrs.
High Back Booster with Harness 30lbs and up
Backless Booster 30lb and up
None

In what shape/condition is the car seat? Provide details:*

Services Needed:*

Check all that apply

Car Seat Check/Education
Car Seat/Education
Car Seat Education Only

Are You Receiving Government Assistance: (Check all That Apply)*

Proof of government assistance will be required

WIC Program
Medi-Cal
CalFresh
Other
None

Referral Submitted By:*

Self
Other Agency
PH Program

If Referral Submitted By "Other Agency", Please List the Agency:

If Referral Submitted By "PH Program", Please List the Program:

Videos*

I have watched the videos above and understand the importance of child car safety.

Additional Comments

Comments

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