Please complete the form below:

Caregiver Name(required)


Caregiver Email(required)


Address: (required)


Vehicle Year(required)


Vehicle Make(required)


Vehicle Model (required)



I understand and agree that:

The purpose of this program is to help reduce improper use of car seats, booster seats, and seat belts and that this inspection is provided as a free-service to me.

This program cannot fully evaluate the quality, safety, or condition of my child restraint or any component of my vehicle, including the seats, seat belt, or LATCH.

This program cannot guarantee my child's safety in a crash and it is important to read both the vehicle and child restraint instruction manuals.

For these reasons, I release all program sponsors, volunteers, and instructors from any present or future liability for any injuries or dangers that may result from a vehicle collision or otherwise.

Upon submission a copy of this form will be sent to the email you entered above. Please bring a signed copy of the form/email to your appointment.