Lakeland Car Seat Registration

To register for a Car Seat Safety Check at the Specialty Care Center of Lakeland, please complete the form below. If you are registering more than three children, you must sign up for more than one time slot because more time will be needed.

To ensure every child travels safely, our program offers car seats at a reduced cost for those that meet program criteria. Convertible seats are available for a donation of $20 and boosters for $10 (cash or money orders only). Prices may vary accommodating special circumstances such as high weight limit. Supplies are limited to 1 car seat per child and appointments are required.

Appointment Date * 
09/20/14, 10:00 AM Booster Seat ONLY Distribution Event (child must be at least 4 years old AND 40 lbs. and present) @ Lakeland Tax Collector's Office, 916 N Massachusetts Ave 
09/20/14, 11:00 AM Booster Seat ONLY Distribution Event (child must be at least 4 years old AND 40 lbs. and present) @ Lakeland Tax Collector's Office, 916 N Massachusetts Ave 
10/06/14, 9:00 AM @ All Children's Outpatient Care, Lakeland, 3310 Lakeland Hills Blvd 
Caregiver First Name * 
Caregiver Last Name * 
City 
County 
Phone *  () - Ext.
Email Address 


Child 1: Age * 
Child 1: Weight * 
Child 1: Height * 
Child 1: Does this
child have any
special needs? * 
Child 1: Does this
child have a
car seat/booster seat? * 
Yes  No 



Child 2: Age 
Child 2: Weight 
Child 2: Height 
Child 2: Does this
child have any
special needs? 
Child 2: Does this
child have a
car seat/booster seat? 
Yes  No 



Child 3: Age 
Child 3: Weight 
Child 3: Height 
Child 3: Does this
child have any
special needs? 
Child 3: Does this
child have a
car seat/booster seat? 
Yes  No 



Comments for Instructor 
* Required