Participation Form
Only parents or legal guardians should fill out this form. We will contact you within 5 business days. The IU Cognitive Develoment Lab respects and protects the privacy of the information you submit to us.
Child's full name:
Last:
First:
Middle Initial:
Please indicate gender: male female
Child's birthdate: (ex: 03/01/00)
Parent's names:
Mother Last:
First:
Father Last: First:
Street address:
City: State: (ex: IN) Zip code:
Home phone number: (ex: 812-555-5555)
Cell phone number: (ex: 812-555-5555)
Work phone number: (optional)
E-mail address: (ex: johndoe@indiana.edu)
Is this your child's first visit to the
Cognitive Development Lab?
no
yes
Does this child have siblings under 6 years of age
who would also like to participate?
yes
no
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