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Car Seat Clinic Registration form
Tuesday, May 13, 2008
Wabasso School Garage
5pm-7pm

Please fill out the entire form below. Appointments will be taken on a first-come first-served basis. Please use the following guide to help you make your appointment.

If you have two or more children you will need to make multiple appointments for the number of children you have. Each child takes 1/2 hour.

Example: You have one 18 month old child and one 5 year old child. Make and appointment for Lane 1 at 5:00pm for the 18 month old and for Lane 1 at 5:30pm for the 5 year old. Your children need to be scheduled for the same lane (unless the option is not available, but do not schedule 2 children for the same time).
 
First Name Last Name
Address
City State Zip
Home Phone Cell Phone
Email Address
Select one: Parent or Grandparent

Appointment Information
Name of Child 1:
Age of Child 1:
Weight of Child 1 (please weigh for current weight):
Height of Child 1 (in inches):
Appointment Time 1:

Name of Child 2:
Age of Child 2:
Weight of Child 2 (please weigh for current weight):
Height of Child 2 (in inches):
Appointment Time 2:

Name of Child 3:
Age of Child 3:
Weight of Child 3 (please weigh for current weight):
Height of Child 3 (in inches):
Appointment Time 3:

*Please be at the school garage 10 minutes prior to your appointment.  Please make sure your vehicle is clean and your children stay buckled in their seats until a technician says it is ok to get out.

Copyright © 2006 Redwood Area Hospital. All rights reserved.
100 Fallwood Road ~ Redwood Falls, MN 56283
507-637-4500/507-637-4999ER

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