Request for Virtual Car Seat Check

If you would like someone to contact you by email to schedule a virtual car seat check, please provide all the information requested on this form, check the hold-harmless agreement box, and click Submit. Then, watch your email for a message from a technician, usually within a couple business days. If you don't hear from a technician after a few days, please send an email to [email protected] to let us know. NOTE: The information you provide will not be shared with anyone for any purpose other than to assist you with the education you've requested on the proper use of your child's car seat.

A car seat checkup is an educational opportunity. Please be sure to prepare in advance by reading your car seat and vehicle owner's manuals. Also, before the meeting, please try installing the car seat on your own. If your baby isn't born yet, be sure to have a doll or stuffed animal on hand so that you can practice harness use.

Caregiver Name*

Name of the person requesting a car seat check (parent, grandparent, nanny, etc.)

First Last

Email*

Enter Email Confirm Email

City/State/Zip Code*

City State ZIP Code

County*

Phone

Virtual Technology*

Most technicians default to using Zoom for virtual checkups. Please confirm that Zoom will work for you by marking it here. Also, please indicate any other technology options you are comfortable with, especially if you cannot use Zoom.

Zoom (preferred)
Teams
FaceTime
Skype
Google Duo

Who Referred You?*

Please tell us who (or what agency) gave you this link. (Or say "I don't know.)

Information about your child

Age 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 a separate form for each child.

Due date?

Please provide the date you are expecting your baby to arrive.

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 Information

So we can prepare for your car seat check, please provide us with the following information about your car seat. If you need to pause to look for this information or don't have it yet, you can go to the bottom of this form to click "Save and Continue Later." If the information is not available (for instance, a label is missing), enter zeros for these required fields.

Car Seat Brand*

Scroll to find the car seat brand name.

Car Seat Model Name*

Car Seat Model Number*

Car Seat Manufacture Date*

Hint: Find the model number and manufacture date on a sticker on the car seat, on its base (if applicable), and/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. If you are still having trouble, you can email us at [email protected] 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.)

Vehicle Information

Please provide us with the following information about your vehicle. (If you do not have a vehicle, enter zeros in these required fields and provide more information in the field provided at the end of this form.)

Vehicle Brand (Make)*

Please indicate the vehicle brand (i.e.: Ford, Toyota, etc.)

Vehicle Model*

Please enter the vehicle model (i.e.: Explorer, Sienna, etc.)

Model Year*

Please enter the model year of your vehicle.

How many rows of seating does the vehicle have?*

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

Other Information

Please use this space to share any additional details or further explain any responses.

Hold-Harmless Agreement*

You must agree to terms of service listed below 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.