Car Seat Check Application Survey

Sponsored by Safe Kids Columbus; led by Piedmont Columbus Regional Midtown

Congratulations on your inquiry for a car seat check-up. You are on the right path to being the best parent you can be and making sure to prevent your child from being severely injured in a car crash. Safe Kids Columbus wants to specify that you are signing up for a car seat check-up, where a certified Car Seat Technician will make sure that your child’s car seat is already installed correctly. Answer the following questions so we can set up your appointment.

Once your car seat check application has been approved you will be contacted by a member of our staff. All car seat check appointments will be on Friday mornings at 9:30am.

1.Parent Contact Information(Required.)

Name (first and last name)

Cell Phone

2.Car Seat Information

Name of car seat (ex: Evenflo, Graco)

Model of car seat (ex: Sonus, Revolve, SnugRide, Nautilus)

3.Vehicle Information

Year

Make (ex: Ford, Chevy, Dodge)

Model (ex: Explorer, Malibu, Journey)

Color

4.Child's Demographics

Due Date, if pregnant

Age of child

Height of child

Weight of child

5.List your concerns when installing your child's car seat

What we need from you at your car seat check-up appointment:

Car Seat manual
Vehicle manual
Please identify the location of your lower anchors and tether anchor prior to the car seat check-up appointment

* Your child does not need to be present at the appointment*

6.Please check all if you accept the policies in place for the appointment

I agree to bring all required materials to the appointment.

I understand I must have installed the car seat to the best of my ability.

If the car seat is not installed or still in the box, I will be asked to reschedule my appointment.

I understand that it is my responsibility to have read the car seat instruction book from cover to cover prior to the appointment.

I understand the maximum amount of time for the appointment is 1 hour.

I understand that it can take 5-7 business days for my appointment to be set up.

I agree not to take or receive phone calls or text messages during my scheduled car seat check appointment in order to keep my focus on learning to properly install and use my car seat.

Although it is not required, donations to Safe Kids Columbus are appreciated in order for us to continue this service.