Child Language & Cognition Lab

Child's Name *

First Name Last Name

Gender *

Date of Birth *

- Month - Day Year

School *

Grade *

Mother/Guardian's Name

First Name Last Name

Father/Guardian's Name

First Name Last Name

Child's Address *

Email Address *

Home Phone Number

- Area Code Phone Number

Mobile Number

- Area Code Phone Number

Preferred method of contacting you *

Email Home Phone Number Mobile Number U.S. Mail

Best time to reach you *

Does your child speak any language(s) other than English? *

Yes No

a) If yes, please indicate.

b) What is the level of proficiency in the other language?

Fluent Conversational Limited

What language is spoken most often at home? *

Does your child have any diagnosed medical problems? *

Yes No

a) If yes, please explain.

Does you child have any academic difficulties? *

Yes No

a) If yes, please explain.

What type of hair does your child have? *

This information helps us determine the type of hair net for your child during the ERP collection of the study.

Straight Curly Thick Afro Braids