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If you are the parent of children 8 years old or younger, we would like to invite you and your children to participate in studies on child development. It is fun and it is an easy way to contribute to society.

Parents Information
Name*:
ZIP Code:
Home Phone:	( ) -
Cell Phone:	( ) -
E-mail*:
Language Information
Are there other languages spoken at home, other than English?	No Yes
If yes, what language(s):
How much?	less than 10% 25% 50% (bilingual) 75% 100% (child is not exposed to English)
Child #1
Name:
Birth Date:	/ /
Full Term:	No Yes
Birth Weight:	lbs oz
Child #2
Name:
Birth Date:	/ /
Full Term:	No Yes
Birth Weight:	lbs oz
Child #3
Name:
Birth Date:	/ /
Full Term:	No Yes
Birth Weight:	lbs oz
Child #4
Name:
Birth Date:	/ /
Full Term:	No Yes
Birth Weight:	lbs oz

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