To register for a Car Seat Safety Check at the Hispanic Outreach Center, 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.

The Hispanic Outreach Center is located at
612 Franklin Street
Clearwater, FL 33756
727-562-4143
(Maps and Directions)

Appointment Date *

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

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