2. Car Seat Inspection - Schedule time with Technician
4. Name*
6. Phone Number:*
8. Car Seat Type(s)*

   1. Rear Facing w/o base
   2. Rear Facing w/ base
   3. Base only
   4. Rear Facing convertible
   5. Forward facing with harness
   6. High back booster
   7. Backless Booster
   8. Specialized Restraints
   9. Vest
10. Child(s) Age in years*

    1. Unborn
    2. 0<1
    3. 1<2
    4. 2<3
    5. 3<4
    6. 4<5
    7. 5<6
    8. 6<7
    9. 7<8
    10. 8<9
    11. 9+
12. Child/Children Information
14. Child #1 weight (lbs)*
15. Child #1 height (in)*
17. Child #2 weight (lbs)
18. Child #2 height (in)
20. Child #3 weight (lbs)
21. Child #3 height (in)
23. Child #4 weight (lbs)
24. Child #4 height (in)
26. Has car seat been involved in a crash?*

    1. Yes
    2. No
27. Do you know the history of the car seat?*

    1. Yes
    2. No
29. Please read*

    1. Yes

    Please bring these items to the car seat check: child/children (unless unborn), car seat manual, and car manual.

31. Time available for the car seat Check?*
33. Any additional comments?
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field