[checkbox checkbox-663 “I am interested in participating in research studies at GSU’s Psychology Department.”] | |||
[checkbox checkbox-179 “I am interested in having my child participate in studies at GSU’s Psychology Department.”] | |||
Full Name: | [text* your-name 20/] | Address: | [text text-439 25/] |
City: | [text text-834 15/] | Zip: | [text text-815 5/] |
Phone: | [tel tel-495 12/ placeholder “XXX-XXX-XXXX”] | Email: | [email email-663 25/] |
Birth date: | [text text-900 12/ placeholder “Mo./D./Yr.”] | ||
Comments: [textarea textarea-87 75×5] | |||
Information about children (if applicable)
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Child 1 Name: | [text text-348 20/] | Child 1 Gender: | [select menu-659 include_blank “Male” “Female”] |
Child 1 Birth Date: | [text text-901 12/ placeholder “Mo./D./Yr.”] | ||
Child 2 Name: | [text text-552 20/] | Child 2 Gender: | [select menu-871 include_blank “Male” “Female”] |
Child 2 Birth Date: | [text text-902 12/ placeholder “Mo./D./Yr.”] | ||
Child 3 Name: | [text text-521 20/] | Child 3 Gender: | [select menu-872 include_blank “Male” “Female”] |
Child 3 Birth Date: | [text text-903 12/ placeholder “Mo./D./Yr.”] | ||
Child 4 Name: | [text text-972 20/] | Child 4 Gender: | [select menu-873 include_blank “Male” “Female”] |
Child 4 Birth Date: | [text text-904 12/ placeholder “Mo./D./Yr.”] | ||
Child 5 Name: | [text text-516 20/] | Child 5 Gender: | [select menu-874 include_blank “Male” “Female”] |
Child 5 Birth Date: | [text text-905 12/ placeholder “Mo./D./Yr.”] |
[submit]
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