Participate with your child Your name * First name & Surname Your contact number Your email * Your child's name * First name & Surname Your child's birthdate: * What is your relationship to this child? * Primary caregiver Other caregiver Other relation Your child's gender * Female Male Gender Diverse Was your child born before his/her due date? Before On due date After If your child was born before/after their due date, how many weeks before/after? Language/s your child is exposed to at home/school/day care etc. (please estimate %): e.g., English 80%, Te Reo 20% Would you consider your child bilingual? Yes No Is your child's vaccination record up to date? Yes No Comments Does your child have any health, cognitive, developmental or behavioural issues that you would like us to know about? Yes No Are you currently pregnant? Yes (please enter your due date: dd/mm/yyyy) No Do you have any other children currently under 7 years of age? If so, feel free to enter their details in a new form OR you can include their information here: Information to include: First name, Surname, gender & birth date. How did you hear about us? Are you interested in receiving an annual newsletter of our research findings and activities? Yes No Comments Captcha
