2021 Child Passenger Safety Week/Seat Check Saturday Car Seat Check Event Registration Form

Complete to register your Child Passenger Safety Week community event held during the week of September 19 - 25, 2021. Registered events will be compiled and shared, upon request for media releases. Events will be provided to PennDOT to share with NHTSA and posted on the PA TIPP website. PA TIPP does not need to be involved in the community car seat check events; we are merely compiling a list of all events to share with PennDOT, NHTSA and statewide community partners. If you are interested in receiving a list of events being held in Pennsylvania, please email aosterhuber@paaap.org. Thank you!

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* 1. Sponsoring Organization and Contact Information

Contact Name:

Organization:

Phone:

Email:

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* 2. What is the date & time of this event?

Start Time

Date

Time

AM/PM

End Time

Date

Time

AM/PM

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* 3. Event Location

Event Location *

Address: *

City: *

State:

ZIP/Postal Code: *

County: *

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* 4. Check whether appointments are required or walk-ins accepted.

Appointments Required

Appointments and Walk-Ins.

Walk-Ins

Virtual By Appointment

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* 5. Make appointment with contact listed above?

Yes

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* 6. If no, who should be contacted for an appointment?

Name:

Phone:

Email:

Thank you for registering your community event. Please share the success of your event by completing the data collection form online at https://surveymonkey.com/r/CPSWeek2021Data or submitting the form found on the last page of the Child Passenger Safety Week 2021 Planner.