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

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 Make / Mfg. (e.g. Ford, Toyota)

Vehicle Moode (e.g. F150, Corolla)

Vehicle Year

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)

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

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:

Child Safety System Product information

Vehicle Information

Child Information