Lakewood Ranch 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

	Lakewood Ranch Car Seat Registration

To register for a Car Seat Safety Check at All Children's Outpatient Care, Lakewood Ranch, please complete the form below.

8340 Lakewood Ranch Blvd., Suite 160
Bradenton, FL 34202
(Find us under Women's Center carport)

Appointment Date *

06/06/13 Check (have your own car seat): 09:00am

06/06/13 Check (have your own car seat): 09:30am

06/06/13 Check (have your own car seat): 10:00am

06/06/13 Check (have your own car seat): 10:30am

06/06/13 Check (have your own car seat): 11:00am

06/06/13 Check (have your own car seat): 11:30am

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