Longitudinal Examination of the Language Development of Children with Autism - DOC

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					Study: A Longitudinal Examination of the Language Development of
Children with Autism/Pervasive Developmental Disorder


Request for more information

*Call (860) 486-2675 or fill out this form (this form is not an obligation to participate)

Parent’s Name:         ____________________

Child’s Name:          ____________________

Child’s Date of Birth: ____________________

Address:
      Street ______________________________

       City/Town ____________________                 State ______

Phone Number: __________________

Email Address: __________________

Child’s Service Provider (school, clinic, etc): ________________________________

Language(s) spoken at home: _____________________________________________

Language(s) spoken at school: ____________________________________________


I am interested in having my child participate in the University of Connecticut
longitudinal study of language development in children with Autism/Pervasive
Developmental Disorders. I understand that giving my address and phone number above
does not commit me to actual participation, but it allows Dr. Naigles’ or Dr. Fein’s
associates to contact me about participation.


______________________________                                ________________________
Parent’s Signature                                            Date


                                   Please mail form to:
                                    Dr. Letitia Naigles
                                University of Connecticut
                               406 Babbidge Rd., Unit 1020
                                  Storrs, CT 06269-1020