MIT KidsBrain Studies
Thank you for your interest in participating in a study in the Department of Brain and Cognitive Sciences at MIT!

The following information will be used only for our lab's purposes, and will not be distributed or made public in any way. The purpose of this form is to help us identify children who meet the criteria (age, gender, etc.) for various studies, and to be able to contact families as they qualify for new studies.

Please fill out a separate form for each child under the age of thirteen in your family.

Child's first name
Please provide just your child's first name.
Your answer
Parent's/Parents' first name(s)
You may put one or both parents' names separated by a comma.
Your answer
Telephone number
Please provide the best telephone number at which to reach you. Feel free to note whether this is a home/work/cell phone number, as well as the best time(s) to call.
Your answer
E-mail address
Please provide the best e-mail address at which to reach you. Feel free to leave more than one e-mail.
Your answer
Preferred Method of Contact
Please indicate whether you would prefer to be reached by e-mail or phone.
Your answer
Child's date of birth
Please provide your child's birthdate in the format MM/DD/YYYY.
Your answer
Gender
Please indicate your child's gender.
Prematurity
Please note whether you child was born prematurely and, if so, how many weeks early (We consider full term to be 37 weeks or greater).
Your answer
Additional information
Please note any other information about your child that you feel might be relevant to our research.
Your answer
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