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[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/]
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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.”]    
       
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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.”]    

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