Language
  • English (US)
  • Español

  • Car Seat Appointment Request Form

    First 5 Yuba County- Car Seat Program
  • Image field 177

  • ⚠️ IMPORTANT: What You Should Know Before Your Appointment ⚠️
    🚗 Our Program: We focus on car seat education and installation support. We are NOT a general free car seat giveaway program. New/replacement seats are distributed on a case-by-case basis while inventory allows.

    🏠 Yuba County Residents Only (Marysville, Wheatland, Plumas Lake, Olivehurst, Beale AFB, Loma Rica, Dobbins, Camptonville, etc.) Note: Yuba City is in Sutter County

    📋 What to Bring:

    • You MUST bring a vehicle (if you don't have access to one, discuss with technician when they call)
    • If you want your child fitted/a replacement seat, you MUST bring the child
    • or If pregnant, please be in your 3rd trimester

    📞 Questions? Call 530-749-4877


    Our technicians CAN:

    ✅ Provide education about car seat safety
    ✅ Help with proper installation techniques
    ✅ Check if your current seat fits your child and vehicle
    ✅ Show you how to use your car seat correctly


    Our technicias CANNOT

    ❌ Fully evaluate your car seat's safety or condition
    ❌ Guarantee your child's safety in a crash
    ❌ Provide warranties about any equipment or services


    Your responsibility: Always read and follow both your car seat AND vehicle manuals.

    🕒 Next Steps: Once you complete this form, a technician will reach out within 3-5 business days to schedule your appointment.

    📞 Questions? Call 530-749-4877

  • Caregiver's Information

    .
  •  -
  • My preferred language is:*

  • Caregiver Date of Birth*
     - -
  • How did you hear about this program?*

  • Vehicle Information

    You will need to have a vehicle at this appointment so we can properly install the car seat. Please let us know what kind of vehicle you plan to bring to this appointment.

  • 1st Child's Information

    For expecting parents, use baby's name (if chosen) or "Baby" and your due date. We schedule appointments within 60 days of your due date.
  • 1st Child's Date of Birth (or expected date)*
     - -
  • For Child 1:*

  • 2nd Child's Information

    For expecting parents, use baby's name (if chosen) or "Baby" and your due date.
  • 2nd Child's Date of Birth (or expected date)
     - -
  • For Child 2:

  • 3rd Child's Information

    For expecting parents, use baby's name (if chosen) or "Baby" and your due date.
  • 3rd Child's Date of Birth (or expected date)
     - -
  • For Child 2:

  • Do you have more than three (3) seats to be inspected? If yes, we will collect the additional information when we call to verify your appointment.

  • Sign the Waiver of Liability

  • I understand and agree that the sole purpose of this program is to help reduce the incidence of improper installation and use of car seats, booster seats and seat belts, and that any inspection, demonstration, education, or car seat provision is being provided as a free service to me. I am participating voluntarily and understand the risks involved.

    I realize that the program sponsors and certified child passenger safety technicians cannot fully evaluate the quality, safety, or condition of my car seat, booster seat, or the vehicle seat, safety belts, or any component of the vehicle now or in the future. No warranties are made about any equipment or services provided. Furthermore, I understand that the actions taken in this program will not guarantee my child's safety in a motor vehicle crash. I understand that it is important to read and follow the instruction manuals for both the vehicle and the car seat.

    For these reasons, I hereby release any program participants and any participating organizations or individuals, including the site owner, from any present or future liability for any injuries, damages, losses, or expenses (including wrongful death) that may result from a vehicle collision, use of any equipment provided, or otherwise, even if caused by their negligence. I also agree to defend and hold them harmless if anyone sues them because of my participation in this program or use of any equipment.

    This release is binding on my heirs and estate. If any part of this release is found invalid, the rest remains in effect.

  • 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

     

  • *If you have any questions when filling out the form call our office at (530) 749-4877.

    Si tiene alguna pregunta al completar el formulario, llame a nuestra oficina al (530) 749-4877.

  • Should be Empty: