Car Seat Check

Car Seat Check
*Tech Only*
Your Information
Name*

First NameLast Name
E-mail*
Phone Number*

Area Code Phone Number
Address
Date of Check*

MonthDayYear
Time of Check

:HourMinutesAM/PM Option
Location of Check

My HomeLindsay's HomeTemple IsraelOther
My address is 31100 Claymore, Farmington Hills. I am at the corner of Claymore and Regency in Rolling Oaks (14 and Drake). Please park at the bottom of my driveway on the street so that we have a flat surface!
The entrance and the playground will be on your right, park to the left in the parking lot by the basketball hoop. You can text me 248-798-2565 when you arrive!
Is there something specific going on with your seat that you would like checked?
Leave blank if NO
Please complete the below information regarding any and all vehicles you will be getting checked and all children whose seats you will be checked

	YES	NO	N/A
If you are bringing more than one vehicle.....will the same children be riding in BOTH vehicles?
Will different children (i.e. grandchildren) be riding in the seat(s) that you will be getting assistance with?
Is this check/install for an unborn child?

Will the parent/guardian of the child be present at the seat check?

YESNOOther
CHILD, CAR SEAT, AND VEHICLE INFORMATION

Please complete as thoroughly as possible
Child Information
Car Seat and Vehicle Information
If you are able to locate, PLEASE take and upload a photo(s) of the date of manufacture sticker(s). It should be located on the side or bottom of the seat/base.

Browse Files

Cancelof
Example of the sticker...
I understand and agree that the sole purpose of this service is to help reduce the incidence of improper child safety seat installation; that this inspection is being provided as a free educational service to me; that this service cannot fully evaluate the quality, safety, or condition of the child safety seat any child safety seat provided or any component of my vehicle, including the seats or safety belts; and that this service cannot guarantee my child's safety in a vehicle collision. I understand it is important to read and follow the instruction manuals for both the vehicle and the car seat. For these reasons, I hereby release Lindsay Cox and any other program participants from any present or future liability for any injuries or damages that may result from a vehicle collision or otherwise. I further agree to fully indemnify and hold the service provider harmless from any liability for injuries arising out of the installation of the car seat.
I agree with the above statement

YesNo
I understand that Lindsay Cox will not be installing my seat for me and leaving, but that she will be teaching and educating me about car seat safety and how to properly install my own seat. I also understand that I will be using hands on techniques to assist and participate in this check/event.
I agree with the above statement

YesNo
Signature

Clear
FINDINGS
Did you view the seat(s) MFG Date and Model Number during check?

YESNO
Did you check to make sure there are no recalls and that the seat(s) is not expired?

YESNO
Photo of MFG Date/Model # (if tech did not see or check during check)

Browse Files

Cancelof
Additional Notes: (to be filled out by tech only)
Tech Last Name: Cox

Tech Number: 732158
Senior Checker

First NameLast Name
Senior Checker Tech ID #
Should be Empty:

Car Seat Check

Your Information

My address is 31100 Claymore, Farmington Hills. I am at the corner of Claymore and Regency in Rolling Oaks (14 and Drake). Please park at the bottom of my driveway on the street so that we have a flat surface!

The entrance and the playground will be on your right, park to the left in the parking lot by the basketball hoop. You can text me 248-798-2565 when you arrive!

CHILD, CAR SEAT, AND VEHICLE INFORMATION

Example of the sticker...