Research Studies at Cincinnati Children's: Information for Parents: CTO

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1. Please check the following

Please check the following   I would like to enter my child (children) into the database for future studies. I would like to enter myself into the database for future adult studies.

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2. Please provide us with information about you.

Please provide us with information about you.   Name:
Address:
City:
State:
Zip:
Daytime phone:
Evening phone:
Email address:
Birth date of parent:
Gender (male or female):

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3. Race/ethnicity (check all that apply):

Race/ethnicity (check all that apply):   African American American Indian Asian Caucasian Hispanic Latino

Other