Thank you for requesting a car seat appointment. If you have more than one child, please fill out the Car Seat Appointment Request Form for each child. Please read the following carefully, fill out the information requested, sign the release form, and submit it. A copy of the form will be sent to your email and a Certified Passenger Safety Technician (CPST) will reach out to you to schedule your appointment.

What you should know about this appointment:

A car seat appointment is an educational interaction between a child’s caregiver(s) and a certified child passenger safety technician (CPST) to promote the safety of the child while riding in a vehicle. This form gathers important information from caregivers that a CPST can use to prepare for a successful appointment. While it is generally preferable to conduct checkups in person, a virtual checkup can provide essential education when it is difficult to arrange in-person interactions, including during inclement weather or when social distancing is imperative. Be advised that you are not guaranteed a free car seat by attending this appointment, but a technician may recommend seat distribution/replacement based on eligibility and observed needs during this interaction.

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Caregiver and Child Information

Caregiver Name*
My native language is...*

I would prefer that written communications and forms be provided in:*

Is the caregiver present an expecting mom?(Y/N)*
Child's Name*

Car Seat Information

To save time during your car seat installation appointment, please fill out the information below for the seat your child is currently using. Find the following information on a sticker on the car seat and/or it’s base. It is also located on the postcard that should be mailed in to register for recalls.
(ie: Baby Jogger, Baby Trend, Britax, Chicco, Clek, Combi, Cosco, Cybex, Diono, Evenflo, Graco, Harmony, Kids Embrace, Nuna, Peg Perego, Uppababy, Urbini, other)
Example: Evenflo MAESTRO
Do you have a hard copy of the owner's manual? (Y/N)

Vehicle Information

To save time during your car seat installation appointment, please fill out the vehicle information below. This information can be found on registration documents, the vehicle owner’s manual, and/or on the sticker inside the driver-side door’s doorframe. You will need access to a vehicle for this appointment.
Do you have a hard copy of the owner's manual? (Y/N)*
Please select ALL methods that would work for you.

Sign the Waiver of Liability

WHEREAS, I have voluntarily sought individual education concerning child safety seat installation conducted by the Capital Area Healthy Start Coalition, inc. and, WHEREAS, I have been informed and advised that the Capital Area Healthy Start Coalition, inc. makes no express, or implied warranties as to the safety or fitness of any child safety seat; and WHEREAS, I have been informed and advised that in order for my child to be fully protected, I must secure my child in the child safety seat properly at all times, and at all times secure the safety seat properly in my vehicle according to the safety seat manufacturer's instruction which have been provided to me and according to the vehicle manual. NOW, THEREFORE, in consideration of being provided with a child safety seat, I hereby agree: 1. That the Capital Area Healthy Start Coalition, inc., its officers, agents, employees, and volunteers, and each of them shall not be responsible or liable for any injury, damage, loss, or expense, either to me or my property incurred by my use of the afore-mentioned child safety seat. 2. I, my heirs, executors, administrators, and assigns hereby agree to defend and indemnify the Capital Area Healthy Start Coalition, inc., its officers, agents employees, and volunteers, and each of them, against any and all manner of actions, causes of actions, suits, debts, claims, demands for damages or liability of expense of every kind and nature incurred or arising by reason of any actual or claimed negligent wrongful act or omission by me relating to the use of the afore-mentioned child safety seat. I hereby represent that I can read, write, and understand the language in which this document is written and that I have carefully read and understand the contents of this document, and that I am of 18 years of age or older.
Signature (Parent/Gaurdian/Caregiver Name) I agree with the terms outlined by the waiver above. And that the information I have provided on this form is correct La Firma (Nombre del padre / tutor / cuidador) Estoy de acuerdo con los términos descritos en la exención anterior. Y que la información que he proporcionado en este formulario es correcta.
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