2. 
6. Your Full Name:
8. Email Address:
10. Phone Number:
14. CHILD # 1 :
16. Date of Birth:
17. Height Measurement:
18. Weight Measurement:
20. CHILD # 2 : (optional)
22. Date of Birth:
23. Height Measurement:
24. Weight Measurement:
30. Vehicle Information :
32. Vehicle # 1 Make:
33. Vehicle Model:
34. Vehicle Year:
36. Vehicle # 2 Make: (optional)
37. Vehicle Model:
38. Vehicle Year:
44. Child Safety Seat:
46. Safety Seat # 1 Make:
47. Model:
48. Purchased New?
50. Safety Seat # 2 Make: (optional)
51. Model:
52. Purchased New?
58. Please select an inspection date from the dropdown menu below and then select a corresponding time for your appointment.
62. Desired Date for Inspection:
    -- Select One --April 6, 2023April 30, 2023May 17, 2023
66. Desired Time-frame:

    Inspections should take 15 - 30 minutes per seat

    1. 7:00 am - 8:00 am
    2. 8:00 am - 9:00 am
    3. 9:00 am - 10:00 am
    4. 10:00 am - 11:00 am
    5. 11:00 am - 12:00 pm
    6. 12:00 pm - 1:00 pm

    1. 3:00 pm - 4:00 pm
    2. 4:00 pm - 5:00 pm
    3. 5:00 pm - 6:00 pm
    4. 6:00 pm - 7:00 pm
    5. 7:00 pm - 8:00 pm
    6. 8:00 pm - 9:00 pm
70. For additional questions or comments, please use the text box below:
74. To complete this request form, please select the SUBMIT button below.

    After your registration, you will receive an email from a member of the WPD prior to your requested appointment.

78. For Additional Safety Information:
    safekids.org
79. Monroe County Safety Information:
    monroecounty.gov/safety-childsafety
Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit Submit and Print

* indicates a required field