Caresource Special Enrollment Form - OhioGuidestone Research Portal

Electronic Agreement *

By checking this box, I agree to use electronic records and electronic signatures.

Staff name

First

Last

For staff use only

Date *

Date of form completion.

Enrollment Information

Participant name *

First

Last

Father's First & Last Name

Participant's date of birth *

Father's Date of Birth

Phone number *

Father's cell phone number.

Father's Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Father's email address.

Is your baby born yet? *

Yes
No

Baby's delivery status (check all that apply)

Baby was born full term 37-42 weeks
Baby was born early under 36 weeks
Baby was admitted or spent time in the Neonatal Intensive Care Unit (NICU)
Baby had health issues
Baby was delivered by C-section

These questions are about your baby. If you baby has not been born yet, please go to the next question.

Baby's date of birth *

If baby has not been born will enter their estimated due date.

Baby's estimated due date *

Day that baby is (or was) supposed to be born.

I give permission for study staff to text me regarding study appointments at the above phone number *

Yes
No

I give permission for study staff to leave me voicemails regarding study appointments at the above phone number *

Yes
No

Emergency contact

First

Last

Emergency contact number

Demographic Information

Primary language spoken at home *

Are you of Hispanic/Latinx heritage? *

Yes
No

Race (please choose all that apply) *

If other, please explain *

Relationship status *

Household family size (includes you, other adults, and children) *

Is the mother of your baby included in your household? *

Yes
No

Who do you co-parent with? *

If other, please explain *

My co-parent's relationship to my child(ren) is *

Examples: Mother, Father, Stepmother, Dad's girlfriend, Mom's partner, Grandmother, Aunt, Foster mother, etc.

How many children do you have.

Selected Value: 0

How did you find out about this study? *