FPG Child Development Institute • University of North Carolina at Chapel Hill • 1-877-696-5797 (toll free)

Who can participate?

Families of children who are:

• 4-14 year old girls with Fragile X Syndrome
• 6-14 year old boys with Fragile X Syndrome
• 6-14 year old girls and boys with Down Syndrome
• 6-14 year old boys with Autism Spectrum Disorder
• 3-6 year old girls and boys who are typically developing

What does participation mean?

Our staff will visit your child once a year for three years. This visit may take place in your child’s school, home, a local clinic, or at the FPG Child Development Institute in Chapel Hill, North Carolina. The project covers travel expenses to and from FPG. Participation includes the following:

• Assessment of your child’s language development
• Completion of questionnaires and a possible interview about your child
• Permission to ask your child’s teacher to complete questionnaires
• Children with fragile X syndrome and/or autism may be asked to provide a blood sample

For each year of participation you will receive $40 and a written summary of your child’s communication skills.

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Yes, I am interested in learning more about this study.

(Please make sure to include your address, email, and phone number so that we can contact you.)

Caregiver's Name
Adddress
Phone
Email
Child's Name
Child's Date of Birth

Child's Gender

Male Female

My child has/is

Fragile X Syndrome
Down Syndrome
Autism Spectrum Disorder
Typically developing

By submitting this, I give permission for the staff of the Frank Porter Graham Child Development Institute to contact me by phone or mail to explain this study further.

As an alternative to submitting this information online, you may also print this page as a blank form, complete, and return to:

Carolina Communication Project
Frank Porter Graham Child Development Institute
The University of North Carolina at Chapel Hill
CB# 8180
Chapel Hill, NC 27599-8180

OR

Call toll-free at 1-877-696-5797