DARIS

Drexel Autism Research Information System

Register

STEP 1

Check all that apply:

I am interested in participating in a future study
I would like to learn more about the AJ Drexel Autism Institute

Step 2

Please indicate who may be eligible for a study

Myself
My Family
Professional

Consent

----PLACEHOLDER FOR CONSENT PAGE----

Step 3

Are you...Is your child...

Diagnosed with ASD:

Yes

Suspected with ASD:

Yes

Other Diagnosis: (Need diagnosis names)

Step 4

Please enter information about yourself and your children..

Guardian (Yourself)

First Name:

Last Name:

Address:

Can we mail you more information? Yes No

Phone #

Type

Provider

Can we text you more information? Yes No

Can we leave you a voicemail? Yes No

Is this your preferred method of contact? Yes No

Email Address

Can we email you more information? Yes No

Is this your preferred method of contact? Yes No

Date of Birth

Gender

Other Gender

Race

Ethnicity

I am diagnosed with ASD Yes No

I think I might have ASD Yes No

Other Diagnosis

Child #1

First Name:

Last Name:

Date of Birth

Gender

Other Gender

Race

Ethnicity

My Child is diagnosed with ASD Yes No

I think my child might have ASD Yes No

Other Diagnosis

To the best of your knowledge, have you has your child ever participated in an AJ Drexel Autism Institute study before? Yes No

Do you allow the AJ Drexel Autism Institute to review the data from previous studies of this person as part of the research process? Yes No

Step 5

To the best of your knowledge, have you has your child ever participated in an AJ Drexel Autism Institute study before?

Yes No

Do you allow the AJ Drexel Autism Institute to review that data from previous studies as part of the research process?

Yes No

Join the AJ Drexel Mailing List!

PERSONAL DATA

[CONSENT PARAGRAPH]

First Name:

Last Name:

Address:

Email Address

Which of the following applies to you?

Drexel Alumni

Guardian/Caregiver of a child with ASD

Researcher

Supporter

Community Partner/Provider

Individual

Other

Thank you for your interest in the A.J. Drexel Autism Institute. If you know someone who may be eligible, please enter your name and their email address below.

Your Name:

Email Address of the Recommended Person:

DARIS

Drexel Autism Research Information System

Register

STEP 1

----PLACEHOLDER FOR CONSENT PAGE----

Step 4

Please enter information about yourself and your children..

Guardian (Yourself)

Can we mail you more information? Yes No

Can we text you more information? Yes No

Can we leave you a voicemail? Yes No

Is this your preferred method of contact? Yes No

Can we email you more information? Yes No

Is this your preferred method of contact? Yes No

I am diagnosed with ASD Yes No

I think I might have ASD Yes No

Child #1

My Child is diagnosed with ASD Yes No

I think my child might have ASD Yes No

To the best of your knowledge, have you has your child ever participated in an AJ Drexel Autism Institute study before? Yes No

Do you allow the AJ Drexel Autism Institute to review the data from previous studies of this person as part of the research process? Yes No

Join the AJ Drexel Mailing List!

PERSONAL DATA

[CONSENT PARAGRAPH]

Which of the following applies to you?

Your data was successfully submitted. Thank you for registering!