Apopka Child Passenger Safety Checklist

Caregiver Information

First Name *

Last Name *

Address 1 *

City *

State *

Zip *

Phone *

Email Address *

I understand and agree that the sole purpose of this inspection is being provided as a free educational service to me from the Apopka Fire Department. *

Signature

*

clear

Todays Date * +

Child Safety System Product Information

Model Number *

Serial Number *

Brand Name /Manufacturer *

Manufacturer Date * +

Date of Purchase * +

History of Child Safety Seat *

This is a New, Never installed Child Safety System?

This Child Safety System was previously used

Yes, I know the history of this previously used Child Safety System

No, I do not know the history of this previously used Child Safety System

Do you have the Manufacturer Guide *

Yes

No

Vehicle Information

Vehicle Make/Mfg. (e.g. Chevy, Buick)

Vehicle Model (e.g. Malibu, Enclave)

Vehicle Year *

Do you have the Vehicle Manufacturer Guide *

Yes

No

Child Safety Seat Desired location in vechile *

Child Information

Will the Child be Present at time of Child Safety System check / Installation?

Yes

No

Year of Birth

Child Age *

Child Weight in pounds *

Child Height in Inches *

Including yourself, what is the
total number of occupants in your vechile at any given time?

How many children under the age of six will be in this vechile on a regular basis, not including the child that this safety system you are requesting to have installed or checked.