Pre-Check Form for In-Person Car Seat Check Caregiver Name* First Last Email* City/State/Zip* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Car Seat Check Event* MM slash DD slash YYYY 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). : Hours Minutes AM PM Information about your childAge of child*Indicate the child's age or if you are still expecting the child. If you are doing checks for multiple children, please fill out the form for each child. 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 Child's Weight*Enter the child's weight in pounds.Child's 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 InformationIt is very important that you provide us with the following information about your car seat and vehicle. If you have trouble finding this information, please email firstname.lastname@example.org right away to ask for help. If the information is not available (for instance, a label is missing), enter zeros for these required fields.Car Seat Brand*Select from these optionsBaby JoggerBaby TrendBritaxChiccoClekCombiCoscoCybexDionoEvenfloGracoHarmonyKids EmbraceMaxi-CosiNunaOrbitPeg PeregoSafety 1stSummerUppababyUrbiniOtherNo car seat yet.Scroll to find the car seat brand name.Car Seat Model Name* Car Seat Model Number* Car Seat Manufacture Date* MM slash DD slash YYYY 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 InformationIt is very important that you provide us with the following information about your car seat and vehicle. If you have trouble finding this information, please email email@example.com right away to ask for help. If the information is not available (for instance, you don't have a vehicle), enter zeros for these required fields.Vehicle Brand (Make)* Please indicate the vehicle brand (i.e.: Ford, Toyota, etc.)Vehicle Model* Please enter the model of your vehicle (i.e.: Explorer, Sienna, etc.)Model Year* Please enter the model year of your vehicle.How many rows of seating in the vehicle?* 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.Hold-Harmless Agreement* You must agree to terms of service before the checkup.By checking the box, you state that you agree to hold harmless all parties involved in offering and conducting this car seat check. You understand that the sole purpose of this program is to help reduce the incidence of improper child safety seat installation; that this checkup is being provided as an educational service to the public; that this program cannot fully evaluate the quality, safety or condition of the child safety seat or any component of a vehicle, including the LATCH system, seats, safety belts and locations of air bags; and that this program cannot guarantee a child’s safety in a vehicle collision. You understand that it is important to read and follow the instruction manuals for both the vehicle and the car seat. For these reasons, I hereby release local, state and national passenger safety programs, certified CPS technicians, and any program participants or agencies for any present or future liability for any injuries or damages that may result from a vehicle collision or otherwise.