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:
28. Vehicle Information :
30. Vehicle # 1 Make:
31. Vehicle Model:
32. Vehicle Year:
34. Vehicle # 2 Make: (optional)
35. Vehicle Model:
36. Vehicle Year:
42. Child Safety Seat:
44. Safety Seat # 1 Make:
45. Model:
46. Purchased New?
48. Safety Seat # 2 Make: (optional)
49. Model:
50. Purchased New?
56. Please select an inspection date from the dropdown menu below and then select a corresponding time for your appointment.
60. Desired Date for Inspection:
    -- Select One --Saturday, July 16, 2022Thursday, July 28, 2022Sunday, August 14, 2022Friday, September 2, 2022Tuesday, September 20, 2022Friday, October 7, 2022Wednesday, October 26, 2022
64. 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
68. For additional questions or comments, please use the text box below:
72. Thank you for completing the request form!
    You will be contacted by a Webster Police Officer to confirm your appointment time.
76. For Additional Safety Information:
    safekids.org
77. Monroe County Safety Information:
    monroecounty.gov/safety-childsafety
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit Submit and Print

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