If you would like to request an appointment, please fill out the form below and a Car Seat Safety Technician will be in touch with you shortly to coordinate an appointment.

If you have any questions or concerns, please contact our Child Passenger Safety Coordinator at 518-371-3880 or via email at safekids@cphmems.org.

Thank you!

First Name

Last Name

Phone

Email

Relationship to child

What is the make and model of your child's car seat Required

Child's Age or Due Date

Is the car seat already installed?

Yes

No

Are there other children that will be passengers in this same vehicle? Required

If so, what are their ages? Required

If applicable, what type of car seat(s) are they in?

How did you hear about us?

Comments

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