Car Seat Application | Comanche Nation

*****Must attened Occupant Protection Class *****

Department:

Injury Prevention

Name:

Address:

Country

Address 1 *

Address 2

City *

State *

ZIP code *

Phone:

Type Of Phone:

Home

Cell

Work

Name of Child

Age
Age:	Weight:	Height:
Age:	Weight:	Height:

Child Date Of Birth:

Gender:

Male

Female

Unborn

Tribal Affiliation /CDIB:

LEGAL GUARDIAN:

Parent

Grandparent

Other

Liability Waiver

I understand and agree the the sole purpose of this program is to help reduce the incidence of improper child safety seat installation; that this inspectionis being provided as a free education service to me; that this program cannot fully evauate the quality, safety or condition of the child safety, any child safety seat provided or any component of my vehicle, including the seats or safety belts; and that this program cannot guarantee my child's saefty in a vehicle collision. i understand that it is important to read and follow the instruction manual for both the vehicle and the car seat. For these reasons, i hereby release Comanche Nation Injury Prevention Program and all current worldwide Safe Kids and National Certified Child Passenger Safety Technicians; and any program participants from any present or future liability for any injuries or damage that may result from a vehicle collision or otherwise.

Informed Consent

I have read and understand the about liability waiver i understand that this program is done for safety and educational purposes and the Comanche Nation does not in any way guarantee or warranty the safety of this child safety seat or inspection, that I will not bring claim against the comanche nation if any injury or death occurs.

Therefore, I hereby release ______________________________________________ And the Comanche Nation form all liabilities involved National Certified Technician's Name:

Office Use Only

Signature Of Applicant:

Date:

Month

Day

Year

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