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Car Seat Assistance Program Application

Thank you for your interest in our car seat program. This program supports families enrolled in HUSKY A by providing education and access to safe, appropriate car seats for children.

Please complete this form to help us determine eligibility and ensure we provide the correct seat for your child. All information will be kept confidential and used only for program purposes.

Once your application is reviewed, a member of our team will contact you with next steps.

Indicates Required

Caregiver Information

Child's Information

Husky A Verification

Used only to confirm eligibility: You will be required to bring your husky card as well as a second form of identification for your child to your appointment, i.e. passport, birth certificate.

Second Child's Information

Husky A Verification

Used only to confirm eligibility: You will be required to bring your husky card as well as a second form of identification for your child to your appointment, i.e. passport, birth certificate.

Third Child's Information

Husky A Verification

Used only to confirm eligibility: You will be required to bring your husky card as well as a second form of identification for your child to your appointment, i.e. passport, birth certificate.

Fourth Child's Information

Husky A Verification

Used only to confirm eligibility: You will be required to bring your husky card as well as a second form of identification for your child to your appointment, i.e. passport, birth certificate.

Demographics

This information helps us improve and fund this program in the future. All responses are confidential.


Husky A enrollment is required to qualify