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 --Thursday, April 8, 2021Wednesday, April 21, 2021

58. April 8th - Desired Timeframe:

    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. April 21st - Desired Timeframe:

    Inspections should take 15 - 30 minutes per seat

    1. 4:00 pm - 5:00 pm
    2. 5:00 pm - 6:00 pm
    3. 6:00 pm - 7:00 pm
    4. 7:00 pm - 8:00 pm
    5. 8:00 pm - 9:00 pm
    6. 9:00 pm - 10:00 pm
66. For additional questions or comments, please use the text box below:

70. 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.

74. For Additional Safety Information:
    safekids.org

75. Monroe County Safety Information:
    monroecounty.gov/safety-childsafety

Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit Submit and Print

* indicates a required field