Welcome Baby Car Seat Safety Program

Welcome Baby Car Seat Safety Program

Interest / Registration Form
For Durham County Residents Only

Class is held at Welcome Baby -721 Foster Street Durham, NC 27701

Please fill out this form and a Welcome Baby staff member will call you to schedule your class.

Please take note of the following:
- To qualify for a car seat, you must complete a 2-hour safety class.
- If expecting, A convertible car seat will be provided no sooner than four weeks before the due date. We do not provide infant carrier car seats.
- Welcome Baby can only give 1 car seat per family every 5 years. We can provide resources if another carseat is needed.
- For families on WIC and/or Medicaid, copay for car seat is $20 (cash).
Parent’s name: *

First NameLast Name
Phone Number*
Please enter a valid phone number.
Can we text you?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Parent Date of Birth*

MonthDayYear
Date
Race

HispanicBlackWhiteAsianNative AmericanOther
Grade Completed by Parent

6789101112Did not complete high school131415161718+
Family Status

Single ParentPartneredMarriedSeparatedDivorcedWidowed
Have you ever been to Welcome Baby before (classes, givingcloset, etc)?*

YesNo
Have you received a car seat from Welcome Baby in the past?*

YesNo
What Year?
Expecting?*

YesNo
Due Date

MonthDayYear
If expecting
Pregnant with twins?*

YesNo
Name(s) of all children under 5 years old in the family

	Child's First Name	Child's Last Name	Birth Date	Weight	lbs or kg
Child #1
Child #2
Child #3
Child #4
Child #5

How many people live in your house?
(Includea baby if you are expecting)
Choose any of the following you receive for yourselfor your child (must verify)

MedicaidHealth ChoiceWIC
Do you own a vehicle?*

YesNo
Year
Make
Model
How did you hear about Welcome Baby?*
Should be Empty: