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Infant Lab Form

Infant and Child Studies Participant Information Form

If you are interested in having your children participate in our studies, please fill out the information below. This information will be entered into a database of potential participants, and we will contact you about any studies that your child can participate in. You are not obligated to participate in any study, and we will remove you from our contact list at any time that you ask.

  * indicates required information

Parents' Names:
      Parent 1:      first *      last *
      Parent 2:      first         last   

Address*:
Address 2: 
City:    State:    Zip Code:

DayTime phone number *: Best time to call:

Email:

How did you hear about us?

What percentage of the time do your children hear English spoken in your home?

If your children hear another language spoken at home, which language do they hear?

 

First child's name*:                                                      
first      last   

First child's gender:  

    Female   Male

First child's birthdate*:    Day  Month     Year
If still pregnant, please enter Due Date as birthdate,
and enter child's first name as "Expected Baby."


    Was your child born more than 3 weeks early?  Yes     No     
If yes, how early was he or she born?

 
    Does your child have a known developmental disability?  Yes     No

 

Second child's name:                                                      
first      last   

Second child's gender:  

    Female   Male

Second child's birthdate:    Day  Month     Year

    Was your child born more than 3 weeks early?  Yes     No     
If yes, how early was he or she born?

 
    Does your child have a known developmental disability?  Yes     No

Third child's name:                                                      
first      last   

Third child's gender:  

    Female   Male

Third child's birthdate:    Day  Month     Year

    Was your child born more than 3 weeks early?  Yes     No     
If yes, how early was he or she born?

 
    Does your child have a known developmental disability?  Yes     No

Fourth child's name:                                                      
first      last   

Fourth child's gender:  

    Female   Male

Fourth child's birthdate:    Day  Month     Year

    Was your child born more than 3 weeks early?  Yes     No     
If yes, how early was he or she born?

 
    Does your child have a known developmental disability?  Yes     No