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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 normal child development. It is fun and it is an easy way to contribute to society.

Parents Information
Name*:
ZIP Code:
Day Time Phone:	( ) -
Night Time 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:	/ /
Birth Weight:	lbs oz
Full Term:	No Yes
Preterm:	No Yes, by weeks.
Child #2
Name:
Birth Date:	/ /
Birth Weight:	lbs oz
Full Term:	No Yes
Preterm:	No Yes, by weeks.
Child #3
Name:
Birth Date:	/ /
Birth Weight:	lbs oz
Full Term:	No Yes
Preterm:	No Yes, by weeks.
Child #4
Name:
Birth Date:	/ /
Birth Weight:	lbs oz
Full Term:	No Yes
Preterm:	No Yes, by weeks.
Please help us by answering a few optional questions
Can you name the location where you picked up our brochure? Did you hear about our study from someone? What convinced you to participate? Can you suggest a location for us to recruit families to participate? Can you share our sign-up page and invite others to become a part of the study? Thank you for signing up today and for answering these questions.

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