Brandon Car Seat Registration

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All Children's Hospital
501 6th Ave South
St. Petersburg, FL 33701
(727) 898-7451
(800) 456-4543

	Brandon Car Seat Registration

To register for a Car Seat Safety Class, please complete the form below. All classes are held at the following location:

Outpatient Care Center, Brandon
885 South Parsons Avenue
Brandon, FL 33511

To ensure every child travels safely, our program offers car seats at a reduced cost for those that meet program criteria.

Appointment Date *

06/14/13, 9:00 AM @ All Children's Outpatient Care, Brandon, 885 Parsons Ave S

07/12/13, 9:00 AM @ All Children's Outpatient Care, Brandon, 885 Parsons Ave S

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

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

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

Comments for Instructor

* Required