Car Seat Program Interest Form

Car Seat Program Interest Program

Richland Public Health's Car Seat Program includes Ohio Buckles Buckeyes (OBB) as funded by Ohio Department of Health and our Infant Car Seat program, thanks to Richland Foundation.

OBB: Convertible Car Seats [rear face from 5-40lbs & 19-40 in] [forward face from 22-65lbs & 29-54in] and Booster Seats [40-120lbs]
Infant Car Seat Program: "click and go" type carrier seats, weight and height limits vary by model.

Please complete this form and you will be contacted by a child passenger safety technician (CPST) to schedule an appointment. Both car seat programs include an education portion that can be completed online or in-person.

Please call 419-774-4726 for more information.

1. Name (First & Last) *This question is required.

2. Email

(please provide if you are interested in the online education course)

This question requires a valid email address.

3. Phone Number *This question is required.

4. Please select all of the following that apply to you: *This question is required.

Richland County Resident
WIC Enrolled
Medicaid Enrolled
WIC/Medicaid Income Eligible
Expectant parent in need of an infant carrier seat

5. Child information: Who needs a car seat?

Age: Years or Months
Height: Inches
Weight: Pounds

Age
Height
Weight

6. Additional children in need of a car seat? *This question is required.

7. Child #2 Information

Age: Years or Months
Height: Inches
Weight: Pounds

Age
Height
Weight

7. Additional children in need of a car seat? *This question is required.

7. Child #3 Information

Age: Years or Months
Height: Inches
Weight: Pounds

Age
Height
Weight