CCRL

CCRL

Sign-Up Form

Please fill out the information below.

We will contact you to set up a time to participate.

 

Child's Information:

*

 

 
 Male
 Female

 

 

 

Best way to reach you:

*

 

*

 

 

 

 

 

Would you like to have supervision
for another child you may bring along?

 
 Yes
 No

 

*
   

Also feel free to contact Dr. Heidi Kloos. 
125 Dyer Hall
Cincinnati , OH 45221-0376
Phone: 513-556-5525
Fax: 513-556-1904
Email: heidi.kloos@uc.edu