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Vehicle Information Please complete the section below for the PRIMARY vehicle that will be used to transport your child(ren). If you would like for a second vehicle to be checked, please note this is in the next section. We can usually accommodate checking as additional vehicle, but please note this will make your appointment run a bit longer. Vehicle Make * Vehicle Model * Vehicle Year * Do you have the original vehicle manual? * YesNoI am not sure The technicians request that, if possible, the original vehicle manual is brought with you to the car seat inspection appointment. This manual includes important specifications about installing car seats specific to your vehicle. Especially in new cars, vehicle manuals can often be found in the passenger glove compartment box. User Acknowledgement: * I will bring vehicle manualI do not have the vehicle manual Child Information How many children do you have that ride in car seats? * 1234 or more Select “1” if expecting first child. Note: The term “car seat” refers to any type of child restraint device used in motor vehicles, such as infant car seats with or without bases, forward- and backward-facing convertible car seats, combination seats, booster seats, etc. Please consider this when completing the below portion. I am the child’s/children’s: * Parent/GuardianGrandparentUncle/AuntOther Caregiver Please specify your (the requester’s) relationship to the child(ren) Appointment Information Note: Requests must be placed at least one week (5 business days) in advance of your requested date. Requests made within the same week of the request will be accommodated as best as possible. Appointments will take place at Livingston Parish Fire Protection District #4 Headquarters in the parking lot located at: 9760 Florida Blvd. Walker, Louisiana 70785 Appointments will be made Monday – Thursday between 8:00 AM – 3:30 PM. Check-ups involving one child/car seat typically take between 30-45 minutes to complete. Please keep this information in mind when completing your request. Preferred dates and times will be accommodated as best as possible. Preferred Date of Check-Up * Check-Up Time * Number Adults Attending * We recommend both/all primary parents/guardians be present, if possible. Will Child(ren) be present? * YesNo Anything else you would like us to know? Second vehicle details (year, make, model); other special requests or considerations. Liability Statement By signing below, I understand and agree that the purpose of this program is to help reduce improper use of car seats, booster seats, and seat belts and that this inspection is provided as a free service to me. This program cannot fully evaluate the quality, safety, or condition of my child restraint or any component of my vehicle, including the seats, seat belt, or LATCH. This program cannot guarantee my child’s safety in a crash and it is important to read both the vehicle and child restraint instruction manuals. For these reasons, I release Livingston Parish Fire Protection District #4, and any of its successors, and any car seat checkup participants from any injuries or damages that may result from the installation or inspection of a child safety seat, the quality or condition of the child safety seat, and any component of my vehicle, that may result from a vehicle collision or otherwise. Signature: * Please type full name to sign Form Submission Disclaimer #1: LPFPD4 staff reserve the right to alter or cancel appointments, confirmed or otherwise, at the staff’s decision due to unforeseen conflicts or emergencies. Disclaimer #2: LPFPD4 does not provide new or replacement car seats. It will be the responsibility of the caregiver(s) to furnish and/or replace car seat(s), should the technician make that recommendation. I understand the terms and liability of this request: * I AgreeI Do Not Agree Submit your completed form via the “Submit” button below, and a technician will follow up with your submission and contact you for an appointment within a few business days. Please check your spam/junk email folders for messages. Thank you!