Car Seat Appointment Form-First 5 Yuba County

If you have any questions when filling out the form call our office at (530) 749-4877.
2nd Child's Information

For expecting parents, use baby's name (if chosen) or "Baby" and your due date.
2nd Child's Name

First NameLast Name
2nd Child's Date of Birth (or expected date)

MonthDayYear
Date
For Child 2:

I have a car seat and just want install supportI have a car seat but think they have outgrown itI have a car seat but it is damaged or has been in an accidentI do not have a seat for them/we are borrowing oneOther
Does your child have any special needs related to car seat usage? (i.e. muscle tone abnormalities, post-surgery recovery, casts or splints, respiratory challenges, neuromuscular disorders, missing limbs, cognitive impairment, challenging behaviors, etc)
Do you have any additional seats you would like inspected during your appointment?

If you have any questions when filling out the form call our office at (530) 749-4877.
3rd Child's Information

For expecting parents, use baby's name (if chosen) or "Baby" and your due date.
3rd Child's Name

First NameLast Name
3rd Child's Date of Birth (or expected date)

MonthDayYear
Date
For Child 2:

I have a car seat and just want install supportI have a car seat but think they have outgrown itI have a car seat but it is damaged or has been in an accidentI do not have a seat for them/we are borrowing oneOther
Does your child have any special needs related to car seat usage? (i.e. muscle tone abnormalities, post-surgery recovery, casts or splints, respiratory challenges, neuromuscular disorders, missing limbs, cognitive impairment, challenging behaviors, etc)
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.

YES, I have more than three (3) seats to be inspectedNO, I only need three (3) seats inspected

If you have any questions when filling out the form call our office at (530) 749-4877.
Is there anything else we should know? (preferred appointment times, specific concerns, or any other information that would help us better serve you)
I understand this appointment does not guarantee a free car seat. Seats are distributed on a case-by-case basis, while supplies last.
Sign the Waiver of Liability
WHEREAS, I have voluntarily sought individual education concerning child safety seat installation conducted by First 5 Yuba County and, WHEREAS, I have been informed and advised that First 5 Yuba County 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 First 5 Yuba County 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 First 5 Yuba County, 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
Sign*

Clear
Should be Empty:

Car Seat Check-Up Events

Caregiver's Information

Vehicle Information

1st Child's Information

2nd Child's Information

3rd Child's Information

Sign the Waiver of Liability