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Car Seat Pre-Check Form

Thank you for requesting a virtual car seat check and/or distribution. 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 Parent/Caregiver:

Name of Child:   Child’s DOB:

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: 

 What technology can you use for a virtual checkup?  Webex    Zoom    GoogleDuo

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?  YES   NO

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, Norman-Mahnomen Public Health 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 Signature:                                       Date:          

   By checking the box and submitting this form, caregiver agrees to these terms and confirms they have watched the Simple Steps Video.