Child Survey

Parent/Legal Guardian, please complete the following survey for each child interested in becoming a panelist for Innovation Research. Interested children must be between the ages of 6 and 18. All information will be used internally by Innovation Research and will be maintained in a confidential manner. * indicates required field *Referred by Referred by: Telephone Telephone: ()- *First Name *First Name: *Last Name *Last Name: *First Name *Parent's First Name *Last Name *Parent's Last Name *Address 1 *Address 1: Address 2: *City *City: *State *State: -Select- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *ZIP *ZIP: *Date of Birth: -Select- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -Select- 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 *Gender: Male Female *Parent/Guardian Primary Telephone: ()- with areacode (Note: This must be a direct line where we can reach a parent/ guardian or leave them a recorded message without going through a receptionist, menu, or switchboard, or using an extension.) Parent/Guardian Alternate Telephone: ()- with areacode (Note: This is a number where our staff could reach a parent or guardian during business hours if needed. There are no restrictions about extensions or switchboards for the number.This may be the same as your primary number.) School District: -Select- Omaha Public Bellevue Bennington Council Bluffs Elkhorn Home School Millard Papillion Ralston Westside Other If Other, list: *Does this child have an allergy to latex? No Yes *Does this child have any known food allergies? No Yes If Yes, state allergies: *How did you hear about us? *How did you hear about us?: -Select- College Campus or event Craigslist Facebook Flyer HyVee Receipt Word of Mouth (family, friends, etc) Omaha Royals game Other Other: If Other: