Name *

First Name

Last Name

Home Phone

(###)

###

####

Cell Phone *

(###)

###

####

Preferred Contact Method *

Phone

Text

Email

Date of Birth *

MM

DD

YYYY

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Do you have hearing loss?

Yes, I have hearing loss

No

Do you have a developmental disability?

Cerebral Palsy

Downs Syndrome

Other

None

Have you been diagnosed with HIV?

Yes, I have been diagnosed with HIV

No

Have you been diagnosed with Alzheimer's disease or Mild Cognitive Impairment?

Yes, I have been diagnosed with Alzheimer's disease or Mild Cognitive Impairment

No

Do you use recreational substances?

Yes, I use recreational substances (e.g. marijuana, methamphetamine, cocaine)

No, I do not use recreational substances.

By agreeing to include your information in the IHN Participant Registry, your information, brain images, test results, and information obtained by the Institute for Human Neuroscience staff will be stored electronically in a secure and password protected location. By agreeing, you may be contacted by IHN research staff for future research studies you may qualify for. Your participation in the IHN Participant Registry is completely voluntary, and you have the right to opt out at any time. There is no penalty for non-participation or withdrawal and your refusal will not affect in any way the services you receive now, or in the future, from IHN, BTNRH, or any associated clinics.

I Agree

I Do Not Agree