Pre-Check Form for In-Person Car Seat Check "*" indicates required fields 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*Select the county you live in. (i.e., King, Snohomish, Pierce, etc.)KingSnohomishIslandPierceSkagitThurstonWhatcomOtherThis field is hidden when viewing the formCounty(i.e., King, Snohomish, Pierce, etc.)Date of Car Seat Check Event*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Registration 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). Hours : Minutes AM PM AM/PM Information about your childAge 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. N/A; unborn Birth to age 1 Over age 1 and under age 2 Over age 2 and under age 3 Over age 3 and under age 4 Over age 4 and under age 5 Over age 5 and under age 6 Over age 6 and under age 7 Over age 7 and under age 7 Over age 8 and under age 12 Over age 12 Weight of Child*Enter the child's weight in pounds.Height of Child*Enter the child's height in inches.This field is hidden when viewing the formWeight and Height of Child Weight (Enter the child's weight in pounds.) Height (Enter the child's height in inches) Car Seat InformationIf you have trouble finding this information, please email info@saferidenews.com 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's brand name.Baby JoggerbabyarkBaby TrendBritaxCenturyChiccoClekCombiCoscoCybexDionoEvenfloGracoHarmonyJoieKids EmbraceMaxi-CosiNunaOrbitPeg PeregoSafety 1stSummerUppababyUrbiniOtherNo car seat yet.Car Seat Model Name*Please enter the car seat's model name.This field is hidden when viewing the formCar Seat Model Name Model Name (Find on labels and/or on the cover of the owner's manual.) Hint: Find the model name on the registration card, owner's manual, or labels. If you have trouble, you can email us at info@saferidenews.com for assistance. (If you do not have a car seat, enter zeros for this required information and explain further in the space provided at the end of this form.)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. Vehicle InformationIf you have trouble finding this information, please email info@saferidenews.com 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.Ford, Toyota, etc.AcuraAlfa RomeoAudiBentleyBMWBuickCadillacChevroletChryslerCODADaewooDodgeEagleFerrariFiatFiskerFordGenesisGeoGMCHondaHummerHyundaiInfinitiIsuzuJaguarJeepKiaLand RoverLexusLincolnLucid MotorsMaseratiMaybachMazdaMercedes-BenzMercuryMINIMitsubishiNissanOldsmobilePlymouthPolestarPontiacPorscheRamRivianRolls RoyceSaabSaturnScionsmartSubaruSuzukiTeslaToyotaVolkswagenVolvoWagoneerVehicle Model*Please enter your vehicle's model name.Vehicle Year*Please enter your vehicle's model year.This field is hidden when viewing the formVehicle Model and Year Model Name Model Year Other InformationAnything else you'd like us to know?.
