Child Passenger Check-up Registration


Parent/Guardian Information

Parent/Guardian Name:
Your Age:
Do you identify as
What is the highest level of school you have completed?
Are you or anyone living in your house getting any assistance? Check all that apply.
No assistance
Food assistance
(food stamps (SNAP), WIC (women, infants, children), free or reduced lunch, food pantry)
Housing assistance
(section 8, utility payment assistance)
Insurance (Medicaid, AR Kids first)
Family aid
(TANF (temporary aid to needy families), AFDC (aid for dependent children, social security)
Work related
(Unemployment, TEA (temporary employment assistance), workers compensation)
Don't know
Prefer not to answer
E-mail Address:
Phone Number:

Child Information

Due Date/Birthday:
Child's Name:
 years & months
Weight and Height:
 pounds inches
Street Address:
City: State: Zip code:

Please describe your child(ren), current car seat use, or special needs
(i.e. type of seat, health conditions, etc.)


Vehicle Information

Vehicle Make:
Model: Year:

Submit Your Form

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