Child Passenger Safety Inspection Request

2. Car seat inspection appointments should be requested at least 2 weeks in advance.

4. Plan on 30-60 minutes per child. There are several factors, such as car seat/vehicle incompatibility that can make the appointment more time-consuming. The child(ren) should be present for the appointment to ensure proper fit of the seat.

6. Name*

7. Email Address

9. Address*

10. City/Zip Code*

12. Phone Number*

13. Year, Make and Model of your car*

15. Preferred Day*

    Check at least 2 options

    1. Monday
    2. Tuesday
    3. Thursday
    4. Friday
16. Preferred Time*

    1. 8am-12pm
    2. 3pm-5:30pm

    When you are contacted for an appointment, you will be given the available times during the time period you select.

18. 1- Child Age/Anticipated Delivery Date*

19. Weight

20. Height

22. Type of car seat currently being used:*

    1. Infant (has carrying handle)
    2. Convertible (switches between front and rear facing)
    3. Front Facing
    4. Booster
    5. Seat Belt
    6. No car seat

23. The car seat/booster

    1. was new when purchased
    2. was used when purchased
    3. was passed down to me by a friend

25. 2- Child Age/Anticipated Delivery Date

26. Weight

27. Height

29. Type of car seat currently being used:

    1. Infant (has carrying handle)
    2. Convertible (switches between front and rear facing)
    3. Front Facing
    4. Booster
    5. Seat Belt
    6. No car seat

30. The car seat/booster

    1. was new when purchase
    2. was used when purchased
    3. was passed down to me by a friend

Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit Submit and Print

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