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Video Car Seat Assistance Program Participant Information Form
This Video Car Seat Assistance Program is meant to be 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 and can provide essential education when in-person car seat checkups are not feasible. All appointments will be conducted via Zoom.
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Email *
First Name *
Last Name *
Phone Number *
Zip Code *
County *
How did you hear about this service? *
Required
Vehicle Make and Model *
Vehicle Year *
Type of Car Seat *
Car seat Brand and Model Name *
Model Number *
Date of Manufacture *
MM
/
DD
/
YYYY
Do you have a copy of the car seat manual? *
Do you have a copy of the vehicle owner's manual? *
Child Height in inches (please type 0 if pregnant/expecting) *
Child Weight in lbs (please type 0 if pregnant/expecting) *
Please read each paragraph and sign/date at the bottom if you understand the limitations on liability of Maryland Kids In Safety Seat staff and volunteers (electronic signature is acceptable). I understand and agree that the sole purpose of the Maryland Kids In Safety Seats (KISS) Video Car Seat Assistance Program is to help answer my car seat and/or vehicle questions.  I realize that the Video Car Seat Assistance Program may be limited in its effectiveness by my inability to provide adequate lighting or wifi/ data connection, which may hinder the Child Passenger Safety Technicians’s ability to fully evaluate the installation inside the vehicle during the video car seat appointment. I acknowledge that pre-reading and installing my car or booster seat(s) prior to my video car seat appointment is my necessary contribution to the process to obtain the best safety guidance.   If KISS staff or volunteers are unable to fully address an issue virtually, I understand that I will be referred to a local nationally certified Child Passenger Safety Technician or car seat inspection event for in-person assistance, and it is my responsibility as the participant to follow up with the recommendations made by staff as restrictions are lifted and in-person car seat inspection options are reinstated.  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 a properly used child safety seat can prevent about 70% of vehicle-related injuries and fatalities among children and that it is important to read both the vehicle and safety seat instruction manuals. I hereby release any program sponsors and Child Passenger Safety Technicians, 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 Video Car Seat Assistance Program or other situation. *
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