Car Seat Class: East Lake

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

	Car Seat Class: East Lake

To register for a Car Seat Safety Check at All Children's Outpatient Care, East Lake, 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.

All Children's Outpatient Care, East Lake is located at 3850 Tampa Road, Palm Harbor, FL 34684. Get maps and directions.

Appointment Date *

06/07/13, 09:00 AM Class (qualify to purchase a car seat):

06/07/13, 10:30 AM Check (have your own car seat):

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