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2. First Name*
3. Last Name*
5. How many seats are you needing assistance with?*
7. Are you needing assistance with a car seat or a booster seat?*
   -- Select One --Car SeatBooster SeatBoth
9. Please select the age group for the child.*

   If you are needing assistance with more than one car seat or booster seat, please select all the age groups that apply. 

   1. 0-6 months
   2. 6-12 months
   3. 12-18 months
   4. 18-24 months

   1. 2-3 years
   2. 3-4 years
   3. 4-5 years
   4. 5+ years
11. Approximate height of the child*
13. Approximate weight of the child*
15. Car Seat or Booster Seat Manufacturer*
17. Car Seat or Booster Seat Model*
18. Car Seat Manufacturer Label
    
20. Car Seat or Booster Seat Manufacturer Date*
22. Please describe any issues you may be having.*
24. What type of vehicle will the seat be installed in?*
26. What time of day would you like an appointment for?*
    -- Select One --MorningAfternoonEvening

    Please be aware that same day appointments may not be available. You will be contacted for scheduling an appointment when a certified car seat technician is on shift. 

28. Phone Number*
30. Email Address*
32. Additional Comments

    Type any comments or additional information here. 

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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field