Recruitment Form

Child Information

Male Female

 

Is the child on any prescription medication? * Yes No

Does the child have any history of mental illness or learning disability? * Yes No

Caucasian
African American

Asian
Native American

Hispanic
Mixed/Other

 

Does the child speak more than one language at home? Yes No
    If so, what language(s)?

Preferred method of contact Phone   E-mail

How did you find out about our lab? *    

By submitting this form you are agreeing to the terms outlined within the disclaimer presented here.

 

* = mandatory

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