KISS Car Seat Assistance Program Caregiver Agreement

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Instructions: Please read and complete the following agreement in order to receive a car seat from the program.

Email *

Date *

YYYY

First Name *

Last Name *

Phone Number *

County of Residence *

Eligibility: Please check all that apply *

Maryland Children’s Health Insurance Program

Medicaid recipient or eligible for Medicaid

Unemployed head of household

Supplemental social security income recipient

Healthy Families Wicomico at Wicomico County Health Dept

Prince George's Child Resource Center

Required

Child Birthdate/Due Date *

YYYY

Are you expecting twins/multiples? *

Yes, I am expecting twins

Yes, I am expecting triplets

If you are currently expecting, what hospital do you plan to deliver at? *

I'm not expecting

Other:

Child Weight in lbs (enter 0 if unborn) *

Child Height in inches (enter 0 if unborn) *

Zipcode *

I agree to complete the product registration form and mail it to the car seat manufacturer to register the car seat. By registering the car seat, I understand that if there is a recall on the seat that I have been provided, the car seat manufacturer will contact me directly with instructions regarding how to correct the recall. I understand that in order for my child to have full benefit of the car seat and to be compliant with Maryland’s Child Passenger Safety Law, I must follow the car seat and vehicle manufacturer’s instructions for every ride. I understand that I am responsible for contacting the Permanent Fitting Station (PFS) for installation assistance to ensure the car seat is installed correctly into my vehicle. A PFS contact has been provided to me. If the car seat is involved in an accident, I understand that I need to contact the car seat manufacturer directly to determine if the car seat needs to be replaced, per their policy and to be compliant with Maryland law. If the manufacturer determines that seat replacement is necessary, I am responsible for the replacement. The Maryland KISS Car Seat Assistance Program is a public service performed in the interest of safety. I understand and agree that the sole purpose of this program is to increase the use of car seats. I understand that the actions taken in this program will not guarantee my child’s safety in a motor vehicle crash. I hereby release any program sponsors, the State of Maryland and its employees, volunteers, and representatives, and any political subdivision and its employees, volunteers, and representatives from any present or future liability for any injuries or damages that may result from the use of this car seat due to a vehicle collision or other situation. (Please type initials below) *

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