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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  No 


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  No 


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  No 


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

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