Randolph Police Department

Child Passenger Safety

To make an appointment, please fill out this form.

• Name                                                                       Phone

First                                               Last

• Email

• Vehicle Year   Vehicle Make     Vehicle Model

• Is your vehicle owner's manual present?

Yes No <\SELECT>

• Child Information

First Last

• Gender

Unborn Female Male <\SELECT>

• Child's Age        Child's Length     Child's Weight

• Does the child have any medical concerns?

Unborn Yes No <\SELECT>

• Safety Seat Information

Infant Convertible Forward Facing High Back Booster Only Other Booster Vest No Seat being used <\SELECT>

• Safety Seat Make              Safety Seat Name             Safety Seat Model

• Date of Manufacture

//

• Is Safety Seat Manual available?

Yes No <\SELECT>