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  • Agreement/ Release of Liability I am the parent/legal guardian of the above named child and understand that this car seat is provided as a public service in the interest of safety. I have been given the manufacturer's and supplemental instructions regarding use and installation of this car seat, and a program representative has demonstrated to me how to put the child in the car seat and how to put the child in the car seat and how to install the car seat and/or locking clip in the motor vehicle. I also agree that if this car seat is involved in a motor vehivlr crash, I will return it to this distribution site immediately. I understand that this organization is not a manufacturer or dealer in car seats and makes no warranty, expressed or implied, as to the fitness of this car seat. I further understand that this organization will assume no responsibility for the consequences(Including Injury) of proper or improper use of the car seat. I agree to forever refrain from insulting, pressing or in any way assisting any claim, demand, action, or cause of action against the organization and its employees, agents or volunteers for any injuries, damages, costs, loss of services growing out of, or which hereafter may grow out of the installation, use, or malfunction of the car seat.
  • I do hereby certify under penalty of law that I have not received an "Operation Car Seat" Voucher in the last 90 days from any other agency for a member of my family. My signature also indicates that my child does not already have a usable car seat appropriate for my child's weight. Type in First and Last Name
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