Apopka Fire Department Safety Seat Inspections Request Form

APOPKA FIRE DEPARTMENT

175 EAST 5TH STREET APOPKA, FL 32703 PHONE (407) 703-1756 FAX (407) 703-1714

Apopka Fire Department

Safety Seat Inspections Request Form

Road injuries are the leading cause of preventable deaths and injuires amoung children. Properly used safety seats can reduce that risk by up to 71 percent. Make sure all passengers are buckled up properly while the care is in motion. Young kids should be correctly secured in a car seat appropriate to their height, weight and age. Always read safety seat insructions and a vehicle oweners's manual to properly install seats. Be sure to register your safety seat to be notified about product recalls. The Apopka Fire Department also provides provides child safety seat checks. Submit a request below. A certified inspector will male sure your safety seat is installed properly.
Today's Date:

Month Day Year
Caregiver Information: *

First Name Last Name
Phone Number

Area Code Phone Number
E-mail
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Requesting

New Safety Seat installation Check already installed Safety Seat
Child Safety System Product information
Model Number*
Serial Number *
Brand Name / Manufacturer
Manufacturer Date

Month Day Year
Date of purchase

Month Day Year
History of Child Safety Seat

This is a New, Never installed Child Safety System This Child Safety System was previously used Yes, I know the history of this previously used Child Safety System No, I do not know the history of this previously used Child Safety System
Do you have the Manufacturers Guide

Yes No
Vehicle Information
Vehicle Make / Mfg. (e.g. Ford, Toyota)
Vehicle Moode (e.g. F150, Corolla)
Vehicle Year
Do you have the Vehicle Manufacturer Guide
Do you have the Vehicle Manufacturer Guide

Yes No
Child Safety Seat Desired location in vehicle

Front Row Middle Front Row (Passenger Side) Back Left (Driver side) Back Middle Back Right (Passenger Side) Third Row Back Left (Driver Side) Third Row Middle Third Row Right (Passenger Side)
Child Information
Will the child be present at the time of Child Safety System check / Installation?

Yes No
Year of Birth
Child age
Child weight in pounds
Child Height in Inches

: Hour Minutes AM/PM Option
Including yourself, what is the total number of occupants in your vehicle at any given time?
How many children under the age of six will be in this vechile on a regular basis, not including the child that this safety system you are requesting to have installed or checked.
Notes:
Should be Empty:

Child Safety System Product information

Vehicle Information

Child Information