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 --Monday, June 5, 2023Thursday, June 29, 2023Monday, July 10, 2023Saturday, July 15, 2023Friday, July 28, 2023Thursday, August 10, 2023Saturday, August 19, 2023Monday, August 28, 2023Sunday, September 3, 2023Wednesday, September 27, 2023
68. Desired Time frame - WEEKDAYS:

    Inspections 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

    1. 3:00 pm - 4:00 pm
    2. 4:00 pm - 5:00 pm
    3. 5:00 pm - 6:00 pm
69. Desired time frame - SATURDAYS:

    Inspections take 15 - 30 minutes per seat

    
    

    1. 11:00 am - 12:00 pm
    2. 12:00 pm - 1:00 pm
    3. 1:00 pm - 2:00 pm
    4. 2:00 pm - 3:00 pm
73. For additional questions or comments, please use the text box below:
77. 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.

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


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit Submit and Print

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