Research Registry Enrollment

Captcha:

Diagnosis:
What type of professional made the diagnosis (e.g., pediatrician, psychologist)?
Date of diagnosis:

The following information will allow us to more effectively identify the studies for which a member of your family may qualify. We store and handle all information with strict regard for confidentiality. All data are stored in a secure location, accessible only to our staff.

Your name:

Parent/Guardian 1

First name:
Last name:
Street:
City:
State:
ZIP:

One of the following phone
Home:
Work:
Cell:

Email:

Race: Asian
Black
Native American
Other
Pacific Islander
White

Ethnicity:
Please indicate the years of education completed:

Parent/Guardian 2

First name:
Last name:
Street:
City:
State:
ZIP:
One of the following phone
Home:
Work:
Cell:

Email:

Race: Asian
Black
Native American
Other
Pacific Islander
White

Ethnicity:
Please indicate the years of education completed:

How did you hear about us? Waisman clinics
Facebook
Internet
Waisman research lab - specify
Other - specify
Waisman event
Friend, relative, or neighbor
Waisman Early Childhood Program

Please complete the following with respect to the children you would like to enroll in the registry. To match your family with studies for which you may be eligible, it is helpful to know the nature of your child(ren)'s medical condition or special needs.

First name:

Last name:

Birth date:

Sex:

Parent/guardian 1 relationship to child: Other:
Parent/guardian 2 relationship to child: Other:

Race: Asian
Black
Native American
Other
Pacific Islander
White

Ethnicity:

Does your child have a developmental disability or diagnosis:

Diagnosis	Who diagnosed	When

Is your child regularly exposed to a language other than English?
If yes, what language?
How many days/wk?
How many hours/day?
Since what age (in months)?

Comments: If your child has medical problems that may interfere with his or her ability to participate in a study, please describe here. Include any hearing loss.

Waisman Center Research Registry