CAR SEAT CHECK REGISTRATION

Are you in need of a Low-Cost Car Seat?*

YesNo
This is NOT the correct FORM!!*
Please call this phone number to be provided the correct link for a low cost car seat. 916-864-5779.
CAR SEAT CHECK:

IMPORTANT: DO NOT fill out this form if you need a car seat for your child and want to apply for our low-income program, instead contact our program at (916) 864-5779. This is for virtual car seat education for caregivers that already have a car seat(s).
Pre-Check Form
Thank you for requesting a car seat check. Please read the following carefully, fill out the information requested, sign the release form, and submit. A copy of the form will be sent to your email and we will send you a confirmation on detail for virtual or in-person appointment.

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/in-person 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, First and Last:*
Age of child (or indicate if unborn):*
Child weight (if born):
Child height (if born):
Address, St., City, State, Zip:
Email:*
example@example.com
Phone:*
Please indicate any special needs relevant to car seat use:
Other children, such as siblings, who regularly ride in the vehicle (age/weight):
Our program will be using Zoom for the virtual checkup. Please provide email or number to be sent a link or be contacted.
Is this a court order child passenger safety education appointment? *
All Court Order Appointments must schedule an IN-Person appointment.
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 MANUFACTURE DATE:*

MonthDayYear
Date
Car Seat MODEL NAME:*
Car Seat MODEL NUMBER:*
Recall purpose
Do you have a hard copy of the owner's manual? (Y/N)
Provide a picture of the front cover car seat manual or a picture of your car seat for our reference.

Browse Files
This will help us identify any specifics on your car seat for the video chat. Cancelof
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/in-person 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 Dignity Health Mercy San Juan Medical Center/ Safe Kids Greater Sacramento Car Seat Program employees, 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.
Signature (Parent/Guardian Name) I agree with the terms and conditions of the virtual car seat check requirements. *

Clear
Date

MonthDayYear
Date
Where did you hear about our car seat program?
We have a few calendars that you can choose to make your appointment. You only need to pick one.

If you are requesting a Virtual car seat check appointment, please choose dates and times from the first calendar.

If you are requesting an In-Person car seat check, you have three locations to choose from for your appointment, Mercy San Juan, Methodist Hospital and Woodland Memorial. (additional calendars). (Court order must schedule in-person appointments).

If dates and times are not available, please leave appointment choice blank and we will contact you for date options. (Due to the program application, available dates may not appear and may need to be updated, so if there's no appointments, please submit and we will contact you, thank you for your patience).
VIRTUAL Car Seat Check Appointments ONLY: Please select a date/time, so we can confirm your virtual appointment.
IN-PERSON Car Seat Check Appointments ONLY: Please select a date/time, so we can confirm your in-person appointment. MERCY SAN JUAN - 6501 Coyle Avenue, Carmichael
IN-PERSON Car Seat Check Appointments ONLY: Please select a date/time, so we can confirm your in-person appointment. METHODIST HOSPITAL - 7500 Hospital Drive, Sacramento
IN-PERSON Car Seat Check Appointments ONLY: Please select a date/time, so we can confirm your in-person appointment. WOODLAND MEMORIAL - 1325 Cottonwood Street, Woodland
Should be Empty:

CAR SEAT CHECK:

Pre-Check Form

Caregiver and Child Information:

Car Seat Information:

Vehicle Information: