Child Car Seat Assistance and Education

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Name: *

I need assistance with: *

Make of Vehicle: *

Model of Vehicle: *

Year of Vehicle: *

Make of Car Seat: *

Model of Car Seat (If Known)

Child's Age *

Weight (Ibs.) of Child *

Child's Height (in.) *

Preferred method of contact: *

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Phone Number (Area code first): *

Email address: *

Today's Date:

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Contact Information