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Application for Child Safety Seat

2. Application for Child Safety Seat
   Fill in form completely.

   Fill in form completely.

4. First Name

5. Last Name

7. Date of Birth

8. Last Four Digits of Social Security No.

9. Phone

11. Address1

13. Address2

15. City

16. State

17. Zip

19. I am requesting a child safety seat for:

    1. My unborn child

    1. My child

21. If for unborn child, due date:

23. If for child, child's name:

24. Birth Date

26. Child' Age (years and months)

27. Child's Weight

28. Child's Height (feet and inches)

30. Child's Race

    1. African American
    2. Caucasian
    3. Asian

    1. Native American
    2. Other

32. If other, please explain:

34. Child's Ethnicity

    1. Hispanic

    1. Non-Hispanic

36. Relationship to this child:

    1. Parent
    2. Legal Guardian

    1. Foster Parent
    2. Other

38. If other, please explain:

40. I am a Virginia resident.

    1. Yes

    1. No

42. I or my child is a US citizen or a documented alien.

    1. Yes

    1. No

44. I or my child receives FAMIS, WIC, Medicaid, or TANF

    1. Yes

    1. No

46. Number (if applicable)

48. Electronic Signature*

    By checking the box below, I am providing my electronic signature.

    1. Sign
50. Applicant's Program Code

    (Applicant's last name plus last four digits of SSN)

52. Applicant met eligibility requirements:

    1. Yes

    1. No

54. Date Approved
    Date Approved

55. Date Training Conducted
    Date Training Conducted

56. Date Safety Seat Issued
    Date Safety Seat Issued

58. Approved applicant showed up for training:

    1. Yes
    2. No

59. Applicant placed on waiting list:

    1. Yes
    2. No

61. Reason(s) Applicant Was Denied:

    1. Supply Depleted
    2. Not Virginia Resident
    3. Income Too High

    1. Child's Age Above Seven Years
    2. Did Not Want to Attend Training
    3. Other

63. If other, please explain:

67. Issue Information

69. Type of Seat Issued

    1. Convertible

    1. Booster

70. Issued As:

    1. Rear facing

    1. Forward facing

72. Informed client to only use with a vehicle lap and shoulder belt:

    1. Yes

    1. No

74. Type of Training Received

    1. Video, Class Instruction, and Hands-on Installation

    1. Video, Class Instruction, and Technician Referral

76. Reason why hands-on installation training was not provided:

78. Name of permanent fitting station or certified technician the client was referred to for installation assistance:

Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

* indicates a required field