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

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