Child Scientist Sign-Up Form

Only parents or legal guardians should fill out this form. We will contact you within 5 business days. The Department of Psychological and Brain Sciences respects and protects the privacy of the information you submit to us.

Child's Full Name:

Last: First: Middle Initial:

Please indicate gender: Male Female

Child's birthdate: (ex: 03/01/09)

Parent's names:

Mother: Last: First:

Father: Last: First:

Street address:

City: State: Zip code:

Home phone number:

Work phone number:

Mobile phone number:

Email address:

Has this child previously participated in an experiment
thru the Department of Psychological and Brain Sciences?

Yes No

Does this child have siblings under 8 years of age
who would also like to participate?

     Yes No
    If yes, please complete additional participation form(s)
    after submitting this one.