Childcare Car Seat Policy Acknowledgment
Please review and acknowledge your understanding of our car seat policy for your child's safety during transport.
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Car Seat Provided By
*
Parent/Guardian
Childcare Provider
Type of Car Seat Used
*
Please Select
Rear-Facing Infant Seat
Forward-Facing Car Seat
Booster Seat
Other (please specify)
If 'Other', please specify the type of car seat:
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Special Instructions or Additional Notes (optional)
Signature of Parent/Guardian (Please sign below to confirm your acknowledgment)
*
Acknowledge and Submit
Acknowledge and Submit
Should be Empty: