Lakeland 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

	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.

Appointment Date *

06/03/13 Class: 10:00 AM, All Children's Outpatient Care, Lakeland, 3310 Lakeland Hills Blvd

07/01/13 Class: 10:00 AM, All Children's Outpatient Care, Lakeland, 3310 Lakeland Hills Blvd

08/05/13 Class: 10:00 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

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