by | Nov 1, 2018

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Learning to Talk Lab- Child Registration
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* Required
Parent/Guardian's First and Last Name *
Your answer
Email address *
Your answer
Phone Number *
Your answer
We like to know how families hear about us. How did you hear about us? *
(Facebook, a friend, website, Infant and Child Studies Consortium, community event, library, Maryland Day, etc.)
Your answer
Child's First name *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Does your child communicate with any language besides English on a regular basis?
Clear selection
If you answered "Yes", please describe below...
Your answer
Does your child have a cochlear implant?
Clear selection
Do you have any additional questions and/or comments?
Your answer
If you would like to sign up more than one child, please add in the additional information below. If you would only like to sign up one child, please scroll to the bottom and click submit.
2nd Child's First Name
Your answer
2nd Child's Date of Birth
MM
/
DD
/
YYYY
Does your 2nd child communicate with any language besides English on a regular basis?
Clear selection
If you answered "Yes", please describe below...
Your answer
Does your 2nd child have a cochlear implant?
Clear selection
3rd Child's First Name
Your answer
3rd Child's Date of Birth
MM
/
DD
/
YYYY
Does your 3rd child communicate with any language besides English on a regular basis?
Clear selection
If you answered "Yes", please describe below...
Your answer
Does your 3rd child have a cochlear implant?
Clear selection
4th Child's First Name
Your answer
4th Child's Date of Birth
MM
/
DD
/
YYYY
Does your 4th child communicate with any language besides English on a regular basis?
Clear selection
If you answered "Yes", please describe below...
Your answer
Does your 4th child have a cochlear implant?
Clear selection
Submit
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