City State Zip Code
Employer, if applicable
Date of crash, if applicable (estimate if exact date is unknown)
Safety belt/Seat belt
Child restraint/Child seat
Not in a crash, but believe seat belts and child seats are essential to safe driving
Year/model of vehicle you were riding in:
Your story is very important. Please describe what happened (500 character limit).
Thank you for your interest in child safety! Best wishes to you.
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