To register for a Car Seat Safety Check at Palm Harbor Fire Rescue, 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 Palm Harbor Fire Rescue is located at
250 West Lake Rd
Palm Harbor, FL 34684
727-784-0454
(Maps and Directions)

Appointment Date *

05/08/2013, 9:30 - 11:30AM

06/12/2013, 9:30 - 11:30AM

07/10/2013, 9:30 - 11:30AM

08/14/2013, 9:30 - 11:30AM

10/09/2013, 9:30 - 11:30AM

11/13/2013, 9:30 - 11:30AM

12/11/2013, 9:30 - 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

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