EARLY ADOPTER TRIAL Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *PhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAre you part of a School or Organisation:YesNoRole: ParentAdvisorTeacherCounsellorOtherExperience with Special needs children:Would you commit to learning watch, looking after it, testing it in conjunction with special needs children and providing your candid feedback?YesNoAre you or your child tech savvy?YesNoSomewhatAre you familiar with smartwatches?YesNoMaybeHow would you describe your family's comfort with new technologies?[Early adopter][Tech-savvy][Some tech use][Prefers older technology]Child's ageChild's diagnoses or description(if any)AutismAspergersBehavioral challengesADD (attention deficit disorder)OtherWhat level of family or community support do you have?Part of a school programAfter school special needs careFamily or community supportHome healthcare workerSpecial needs tutor or assistantOtherWe're particularly looking for more opportunities to work with in-school use. Is there some potential for your school or PTA to help evaluate the watch experience?I'd like to give feedback in context of school use and feel my child's school will be amenable to itI'd prefer to evaluate the watch independently of school contextI'd like to try to evaluate in both settingsOther:Now or in the future, would you be able to work within a school program context eg give feedback in context of school use?YesNoMaybeOther:Would you be willing to give feedback on your experience with the watchYesNoMaybeDo you have 20 min available us to guide you with the watch setup?YesNo Thanks for Your Time. We’ll send you an email to set up an appointment with an official Brainwave Advocate. Your Advocate will discuss your needs and answer your questions, Setup is easy! We'll arrange a mutually convenient time and walk you through the setup. The process only takes about 20 minutes and we'll help you and your family get the watch ready to go For the trial, all we will ask is to do some brief talks (about 30 minutes long) to see how useful and effective your experience has been We appreciate your time and we look forward to speaking with you further. Upon your completion of the form, we will email you an acknowledge. IMPORTANT! If your acknowledgement email does not arrive in the next few minutes, please check your Spam box and mark it as “Not Spam”Submit
