Pre-Check Form for In-Person Car Seat Check

Caregiver Name*

NOTE: PLEASE ENTER A LAST NAME THAT MATCHES THE NAME GIVEN WHEN REGISTERING WITH THE HOSPITAL. (If you are not sure—for instance, if a spouse registered— please provide both last names used in your household.)

First Last

Email*

City/Zip*

City ZIP Code

County*

Date of Car Seat Check Event*

Registration Time (Time of Arrival)*

Before completing this form, you must register for the event through the host hospital. If you haven't done so, please contact the hospital to register; return to the form when you have been assigned a registration time. NOTE: Each registration time should be for one child, one car seat, and one car. If you have more than one of any of these, please register them for separate times (and fill out a form for each).

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Information about your child

Age of child*

Indicate the child's age or if you are still expecting the child. IF YOU HAVE MULTIPLE CHILDREN/APPOINTMENTS, PLEASE FILL OUT SEPARATE FORMS FOR EACH.

Weight and Height of Child

Weight (Enter the child's weight in pounds.) Height (Enter the child's height in inches)

If applicable, please describe any special needs that affect this child's use of a car seat:

Please describe other regular riders in rear seats, including siblings (whether or not also being checked). Please include ages and type of child restraint, as appropriate.

Car Seat Information

We need the following basic information about your car seat and vehicle so we can prepare for your car seat check. If you have trouble finding this information, please email [email protected] to ask for help. IF YOU HAVE MULTIPLE CAR SEATS/APPOINTMENTS, PLEASE FILL OUT SEPARATE FORMS FOR EACH.

Car Seat Brand*

Scroll to find the car seat brand name.

Car Seat Model Name*

Model Name (Find on labels and/or on the cover of the owner's manual.)

New or Used?*

If this car seat was purchased second-hand or borrowed (used by another child) please indicate "Used" along with status of owner's manual.

New
Used, and I have the owner's manual
Used, and I don't have the owner's manual.

Find the model number and manufacture date on a sticker on the car seat, on its base (if applicable), or on the registration card. The sticker is usually on the side, back, or underside of the car seat. If you have trouble finding the sticker, the owner's manual should help guide you to it.

Vehicle Information

We need some information about your vehicle so we can be prepared for your checkup. If you have trouble finding this information, please email [email protected] to ask for help. IF YOU HAVE MULTIPLE VEHICLES/APPOINTMENTS, PLEASE FILL OUT SEPARATE FORMS FOR EACH.

Vehicle Brand (Make)*

Scroll to find the vehicle brand name.

Vehicle Model and Year*

Model Name Model Year

How many rows of seating are in the vehicle (total)?*

One row (no back seat)
Two rows
Three rows
More than three (i.e.: full-size van)

Other Information

If you'd like to share any additional details or further explain any responses, please do so here.