CHILD contact update

Thank you in advance for completing the form below. Your responses will be provided directly to the coordinator at the Study site to which you were originally recruited (Vancouver, Edmonton, Winnipeg & Morden/Winkler, Toronto).

If our last contact with you was at the time of your 5-year visit with CHILD or before then, we will be issuing you $20 in the form of a Tango Gift Certificate, redeemable with 1000+ vendors, for your time.

Name *

First

Middle

Last

Previous last name (if changed)

Email *

Phone *

Date of birth (DD/MM/YYYY) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please indicate the original CHILD site to which you were recruited: *

Vancouver
Edmonton
Winnipeg & Morden/Winkler
Toronto

Comments or questions?