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2. Appointment Information

   Request an appointment for a Safe Kids car seat clinic, your appointment is NOT scheduled until confirmed by a Safe Kids Technician. You will be contacted by a technician to confirm your requested appointment date and time.

4. Parent/Caregiver Name:

   First name, last name

6. Phone number:
8. Email:
10. What Anoka County city do you reside in?
12. Make, model, year and color of your vehicle(s) *
14. Age(s) of child(ren) *
16. Number of seats to install *
18. Make and model of car seats: *
20. Primary Date and Time Requested for Appointment:
    Primary Date and Time Requested for Appointment:

    Primary Date and Time Requested for Appointment:
22. Secondary Date and Time Requested for Appointment:
    Secondary Date and Time Requested for Appointment:

    Secondary Date and Time Requested for Appointment:
24. Other notes:
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field