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2. If you want to apply for a FREE car seat, please proceed to this form:

   https://www.cityhall.lima.oh.us/FormCenter/Fire-Department-Forms-2/Child-Passenger-Safety-Seat-Request-104

   
   

   If you want to have your current seats checked, please fill out the information below:

4. Driver's First Name*
5. Driver's Last Name*
7. Driver's Address 1*
9. Driver's Address 2
11. City*
12. State*
13. Zip*
15. Phone Number*
16. Email Address*
20. Vehicle Make*
21. Vehicle Model*
22. Vehicle Year*
24. Number of Children Riding in Vehicle
    -- Select One --123456
26. Age of Child 1
    -- Select One --< 1123456789+
27. Age of Child 2
    -- Select One --123456789+
28. Age of Child 3
    -- Select One --123456789+
30. Age of Child 4
    -- Select One --123456789+
31. Age of Child 5
    -- Select One --123456789+
32. Age of Child 6
    -- Select One --123456789+
34. I understand and agree that the sole purpose of this program is to help reduce the incidence of improper installation and use of car seats, booster seats and seat belts, and that this inspection and demonstration is being provided as a free educational service to me. I realize that the program sponsors and certified child passenger safety technicians inspecting the seat(s) cannot fully evaluate the quality, safety, or condition of my car seat, booster seat, or the vehicle seat, safety belts, or any component of the vehicle now or in the future. 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 it is important to read and follow the instruction manuals for both the vehicle and the car seat. For these reasons, I hereby release any program participants, any participating organizations or individuals, including the site owner, from any present or future liability for any injuries or damages that may result from a vehicle collision or otherwise.
36. Agree/Disagree*
    -- Select One --AgreeDisagree
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field