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January 9, 2015
Seth Pollak, PhD
Current ResearchTeaching & EducationPeopleCommunity OutreachFor Parents Publications

Research Registration Form

Thank you for your willingness to participate in our child development research. Our research would not be possible without the generosity of families like yours.
Once we receive your information, we will contact you when we have a research opportunity to offer your family. At that time, we will explain to you the details of the study and you decide if you want to participate in that particular study.

Family Contact Information

Parent(s) first and last names:  
Street address:  
City/State/Zip: 
Home phone: 
Work phone: 
Cell phone: 
Email address: 
How did you hear about our lab?

Child One

Name (first and last):  
Gender:
Date of Birth:  
Birth Child?
Complete if child was adopted domestically.
Age at adoption:
Placement prior to adoption:
Complete if child was adopted internationally:
Age at adoption:
Placement prior to adoption:
Country of origin:

Does this child receive any therapies or special instruction at school?
If so, please describe.

Does this child have significant health concerns?
If so, please describe: