Clinical Trial Research | Arkansas Children's Hospital

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Parent Registration

Please complete the following form to register for your child to participate in clinical trials at the Arkansas Children's Hospital Research Institute. After you submit this form, you will be able to add as many children to your profile as you wish through "View My Profile."

Your information will be kept confidential, and it will only be used to match you with trials that meet your criteria and to contact you in regards to your participation. If you have any questions, please contact ACHRI at 501-364-7373.

Parent's Name	Last First
Street Address
City
State
Zip
Home Phone
Okay to leave message at home?	Yes
Work Phone
Okay to leave message at work?	Yes
Email Address
Password for this site

By entering my initials in the field below and clicking Submit, I hereby authorize Arkansas Children's Hospital Research Institute to retain this information and to use this information internally solely to assess my eligibility for current/future research studies or to inform me of current/future research studies. I understand and agree that the information I have provided will not be disclosed or sold to any third party.

Please check this box to indicate you have read and agree with the above terms.

Your Initials Date of Submission

Arkansas Children's Hospital, 800 Marshall St., Little Rock, AR 72202-3591, (501) 364-1100 or TDD (501) 364-1184

ACH is a tobacco free campus.