Boston College Infant and Child Cognition Lab Participation Survey

Thank you for your interest in participating in a study with the Boston College Infant and Child Cognition Lab! Please fill out this short survey and we will contact you soon.

Parent/Guardian Name (First and Last):

Parent/Guardian Email:

Parent/Guardian Phone Number:

Preferred method of contact:

Phone
Email
Both

Family Zip Code:

Please enter the name (first and last), DOB (mm/dd/yyyy), grade entering in the Fall (if applicable), gender, and languages spoken of the child or children you would like to participate in our studies. Also, please indicate if they are deaf or hard of hearing (DHH)

Please enter the **name (first and last)**, **DOB (mm/dd/yyyy)**, **grade entering in the Fall (if applicable)**, **gender**, and **languages spoken** of the child or children you would like to participate in our studies. Also, please indicate if they are **deaf or hard of hearing** **(DHH)**
	Name	DOB (mm/dd/yyyy)	Grade	Gender	Languages Spoken	DHH (yes/no)
Child #1	Child #1	Child #2	Child #3
Child #2	Child #1	Child #2	Child #3
Child #3	Child #1	Child #2	Child #3
Child #4	Child #1	Child #2	Child #3
Child #5	Child #1	Child #2	Child #3

Has your child been diagnosed with a learning or developmental disability?

(note: we are not currently recruiting children with intellectual disabilities)

Yes (if so, please specify the nature of the diagnosis and which child was diagnosed)
No
Prefer Not to Answer

To confirm you are not a robot, please answer this question:

Thank you for your participation!