Boston College Infant and Child Cognition Lab Participation Survey

Thank you for your interest in participating in a study, Math, Space, and Reading, 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, and gender 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,** and **gender** 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)	Gender	Grade (if summer, enter grade they will enter in fall)	DHH (yes/no)	Languages Spoken
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?

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

Thank you for your participation!

Answering the captcha is required to proceed