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Child Safety Seat Check Request Form:

2. Car Seat Safety Check Request Form: Please use this form to request a Child Safety Seat Inspection. Safety seat appointments are done Tuesdays, Thursdays and the 1st Saturday of every month between 10:00 a.m. - 3:00 p.m. Appointments must be requested a week in advance and could take approximately 1 hour. At times, in the event of an emergency response, the car seat technician may need to leave, and the appointment rescheduled. Someone will contact you within 24 - 48 hours to confirm your appointment.

   Car Seat Safety Check Request Form: Please use this form to request a Child Safety Seat Inspection. Safety seat appointments are done Tuesdays, Thursdays and the 1st Saturday of every month between 10:00 a.m. - 3:00 p.m. Appointments must be requested a week in advance and could take approximately 1 hour. At times, in the event of an emergency response, the car seat technician may need to leave, and the appointment rescheduled. Someone will contact you within 24 - 48 hours to confirm your appointment.

4. Name*

5. Phone Number*

7. Address

9. City

10. State

11. Zip Code

13. email:*

14. Alternate Phone Number:

18. Vehicle Make:*

19. Vehicle Model:*

20. Vehicle Year:*

22. 2nd Vehicle Make:

23. 2nd Vehicle Model:

24. 2nd Vehicle Year:

26. Number of Car Seats:*

28. Car Seat Manufacture and Model:*

29. Car Seat Serial Number*

30. Car Seat Manufacture Date:*

32. Second Car Seat Manufacture and Model:

33. Second Car Seat Serial Number:

34. Second Car Seat Manufacture Date:

36. **If you have more than two car seats please contact Rachael Gonzales at 970.568.3232.**

    **If you have more than two car seats please contact Rachael Gonzales at 970.568.3232.**

40. Reminder: Safety seat inspections are done on Tuesday, Thursday, and the 1st Saturday of every month between 10:00 - 3:00 p.m.. Appointments must be requested a week in advance and could take approximately 1 hour.

    Reminder: Safety seat inspections are done on Tuesday, Thursday, and the 1st Saturday of every month between 10:00 - 3:00 p.m.. Appointments must be requested a week in advance and could take approximately 1 hour.

42. Preferred Option:
    Preferred Option:

    Preferred Option:

43. Second Option:
    Second Option:

    Second Option:

45. Additional information:

Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit Submit and Print

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