Fillable 14266 Pre Form (City of Apple Valley)

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14266 Pre Form (City of Apple Valley)

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VIRTUAL CAR SEAT CHECK:
Pre-Check Form
Thank you for requesting a virtual car seat check. Please read the following carefully, fill out the
information requested, and sign the release form. Return the completed form per instructions provided when
the form was sent to you. If accessing this form online, save it to a computer so it can be filled out, saved, and
sent electronically.
What you should know about this checkup:
A car seat check (checkup) is an educational interaction between a child’s caregiver(s) and a certified
child passenger safety technician (CPST) to promote the safety of the child while riding in a vehicle. This
form gathers important information from caregivers that a CPST can use to prepare for a successful virtual
car seat check. While it is generally preferable to conduct checkups in person, a virtual checkup can
provide essential education when it is difficult to arrange in-person interactions, including during inclement
weather or when social distancing is imperative. Ideally, follow up afterward by scheduling an in-person
checkup when conditions allow, if possible.
Caregiver and Child Information:
Name of caregiver: _________________________________________________________________________
Age of child (or indicate if unborn): __________________________________________________________
Child weight (if born): _______________________________________________________________________
Child height (if born): ________________________________________________________________________
Address, St., City, State, Zip: ___________________________________________________________________
Email: ______________________________________________________________________________________
Phone: ______________________________________________________________________________________
Please indicate any special needs relevant to car seat use: ____________________________________
_____________________________________________________________________________________________
Other children, such as siblings, who regularly ride in the vehicle (age/weight):
_______________________________________________________________________________________________
What technology can you use for a virtual checkup? (i.e: FaceTime, Skype, Zoom, GoogleDuo): _____________________________
Car Seat Information:
Find the following information on a sticker on the car seat and/or it’s base. It is also located on the postcard
that should be mailed in to register for recalls.
Car Seat BRAND:
(ie: Baby Jogger, Baby Trend, Britax, Chicco, Clek, Combi, Cosco, Cybex, Diono, Evenflo, Graco, Harmony,
Kids Embrace, Nuna, Peg Perego, Uppababy, Urbini, other)
Car Seat MODEL NAME: Car Seat MODEL NUMBER:
Car Seat MANUFACTURE DATE:
Do you have a hard copy of the owner’s manual? (Y/N)
Is the car seat part of a travel system (stroller)? (Y/N)
Vehicle Information:
Find the following information on registration documents, the vehicle owner’s manual, and/or on the sticker
inside the driver-side door’s doorframe.
MAKE (i.e. Ford, Toyota): MODEL (i.e. Escape, Sienna):
MODEL YEAR: MODEL STYLE (i.e. van, SUV, sedan, convertible):
Number of seating position in rear row(s) of vehicle:
Do you have a hard copy of the owner’s manual? (Y/N)
Sign the hold-harmless agreement:
I understand and agree that the sole purpose of this program is to help reduce the incidence of improper child
safety seat installation; that this virtual checkup is being provided as an educational service to me; that this
program cannot fully evaluate the quality, safety or condition of the child safety seat or any component of my
vehicle, including the LATCH system, seats, safety belts and locations of air bags; and that this program cannot
guarantee my child’s safety in a vehicle collision. I understand that it is important to read and follow the
instruction manuals for both the vehicle and the car seat. For these reasons, I hereby release local, state and
national passenger safety programs, certified CPS technicians, and any program participants or agencies for
any present or future liability for any injuries or damages that may result from a vehicle collision or otherwise.
________________________
_____________
________________________________________
(Parent/Guardian Name)
Phone Date
By checking the box and returning this form, caregiver agrees to these terms Date:_________________
This material was originally developed by Safe Ride News Publications and
Washington State’s Child Passenger Safety Program, and happily shared with
our partners in the child passenger safety community.
(the postcard is located on new car seats only)
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14266 Pre Form (City of Apple Valley)

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Completed 8 May 2022

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