Boston College Infant and Child Cognition Lab Participation Survey

Thank you for your interest in participating in a study, Motivating Others, 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!

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