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2. Email

   Your email

4. How did you hear about the car seat check program?

   1. Friend/Family Recommendation
   2. Monroe Police Department Website
   3. Other Agency's Website
   4. Social Media (Facebook, Twitter, Instagram)
   5. Other:
6. Full Name:
8. Email:
10. Phone Number:
12. City and Zip Code:
14. What is your primary language?
16. Child Information

    If child is not born yet, write unborn in your answers.

18. Child Weight (if born):
20. Child Height (if born):
22. Child Date of Birth (mm/dd/yyyy) OR Expected Due Date:
24. Please indicate any child special needs relevant to car seat use:
26. Other children, such as siblings, who regularly ride in the vehicle (age/weight):
28. Will child be present for the car seat check?

    1. Yes
    2. No
30. 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.

32. Model Year:
34. Make (i.e. Ford, Toyota, Subaru, etc):
36. Model (i.e. Escape, Sienna, Outback, etc):
38. Model Style (i.e. van, SUV, sedan, convertible):
40. Do you have a hard copy of the owner's manual?

    1. Yes
    2. No
42. 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.

44. Please list your current 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)
46. Car Seat Model Name:
48. Car Seat Model Number (example below):
    
50. Your answer
52. Car Seat Manufacture Date:
54. Do you have a copy of the car seat owner's manual?

    1. Yes
    2. No
56. Installation Method: Do you want the car seat installed using LATCH or seatbelt? (Both are equally safe)
    -- Select One --LATCHSeatbelt
58. Questions/Comments
60. Read release form in its entirety.

    CAR SEAT CHECKS & SEAT DISTRIBUTION PROGRAM
     
    WAIVER OF LIABILITY & ASSUMPTION OF RISK

    
    PLEASE READ CAREFULLY

    The goal of the Monroe Police Department Car Seat Checks Program (“Program”) is to help reduce the incidence of improper installation and use of car seats, booster seats, and seat belts.  Monroe Police Department cannot fully evaluate and does not warrant or guarantee the quality, safety, or condition of any car seats, booster seats, vehicle seats, safety belts, or any other vehicle components.  Monroe Police Department encourages you to read and follow the instruction manual(s) for any vehicle that you operate or ride in and any car seats, booster seats, vehicle seats, safety belts, or any other vehicle components.

    Release, Indemnification, and Hold Harmless

    FOR AND IN CONSIDERATION OF MONROE POLICE DEPARTMENT ALLOWING THE UNDERSIGNED TO PARTICIPATE IN THE PROGRAM, THE UNDERSIGNED FOR THEMSELVES, MARITAL COMMUNITY, HEIRS, EXECUTORS, ASSIGNS, AND ANY INDIVIDUAL USING OR RIDING IN THE UNDERSIGNED’S VEHICLE INSPECTED AS PART OF THE PROGRAM OR OTHERWISE USING A VEHICLE COMPONENT PROVIDED TO THE UNDERSIGNED AS PART OF THE PROGRAM, DOES HEREBY FOREVER RELEASE, INDEMNIFY, AND HOLD HARMLESS MONROE POLICE DEPARTMENT, ITS EMPLOYEES, AND ANY AND ALL ORGANIZATIONS AND INDIVIDUALS  ASSOCIATED WITH THE PROGRAM FROM ALL CLAIMS, DAMAGES, DEMANDS, OR INJURIES OF ANY KIND (ANTICIPATED OR UNANTICIPATED) OR NATURE (UP TO AND INCLUDING DEATH) ARISING OUT OF OR RELATING TO THE UNDERSIGNED’S PARTICIPATION IN THE PROGRAM.

    Assumption of Risk

    BY PARTICIPATING IN THE PROGRAM, THE UNDERSIGNED ASSUMES ALL RISK OF PROPERTY DAMAGE OR BODILY INJURY THAT ARISES FROM OR RELATES TO THE UNDERSIGNED’S PARTICIPATION IN THIS PROGRAM.

62. I accept the conditions printed above:

    Your initials here indicate you agree to be bound by the provisions of this Release Form.

64. Please type your full name indicating you agree to provisions in the Release Form.
66. Thank you for your request.

    Someone will contact you within the next 48 hours regarding setting up a date/time for the car seat inspection.

Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field