Car Seat Inspection Request

2. 
4. Your Full Name:
6. Email Address:
8. Phone Number:
12. CHILD # 1 :
14. Date of Birth:
15. Height Measurement:
16. Weight Measurement:
18. CHILD # 2 : (optional)
20. Date of Birth:
21. Height Measurement:
22. Weight Measurement:
26. Vehicle Information :
28. Vehicle # 1 Make:
29. Vehicle Model:
30. Vehicle Year:
32. Vehicle # 2 Make: (optional)
33. Vehicle Model:
34. Vehicle Year:
38. Child Safety Seat:
40. Safety Seat # 1 Make:
41. Model:
42. Purchased New?
44. Safety Seat # 2 Make: (optional)
45. Model:
46. Purchased New?
50. Please select an inspection date from the dropdown menu below and then select a corresponding time for your appointment.
54. Desired Date for Inspection:
    -- Select One --Friday, June 25, 2021
58. June 25th - Desired Time-frame:

    Inspections should take 15 - 30 minutes per seat

    1. Noon - 1:00 pm
    2. 1:00 pm - 2:00 pm
    3. 2:00 pm - 3:00 pm
    4. 3:00 pm - 4:00 pm
    5. 4:00 pm - 5:00 pm
    6. 5:00 pm - 6:00 pm
    7. 6:00 pm - 7:00 pm
62. For additional questions or comments, please use the text box below:
66. Thank you for completing the request form!
    You will be contacted by a Webster Police Officer to confirm your appointment time.

    You will be contacted by a Webster Police Officer to confirm your appointment time.
70. For Additional Safety Information:
    safekids.org
71. Monroe County Safety Information:
    monroecounty.gov/safety-childsafety
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit Submit and Print

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