Jefferson College of Health Professions - Center for Applied Research on Aging and Health

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Registry Form

Please fill out the registration form below if you would like further information about volunteering as a study participant in any of the IRB-approved research projects conducted by the Center. All information given will be maintained in a secure database that is accessible only by CARAH personnel and will not be used for solicitation purposes. All participation in Center research projects is strictly voluntary. The information that you provide consists of your address and answers to questions characterizing your interests.

All research participants receive payment for interviews conducted in their home. There is no cost to participating in any part of the program. Participation does not affect services received through other agencies.

Once registered in our research volunteer database, you may remove yourself from the registry at any time. You may also change your profile information at any time. To change information, Click on “Contact Us” located in the left hand column on any page, enter “Changes to Registry” as the subject of an email and send it to the address provided. Please include your name and any additions and/or modifications to your information in the text of the email. Or you can write “Unsubscribe” as the title of the email. You may unsubscribe when you receive information about a study by replying and typing “unsubscribe” as the subject of the email.

In order for us to best help you, please answer the following questions.

* Required fields

Please indicate your gender: Male Female

* Date of Birth:

Have you ever participated in any of our research projects before? Yes No

Are you caring for someone with dementia or a related memory problem? Yes No

(If yes) Do you live with the person you are caring for? Yes No

* Please indicate what studies may be appropriate for us to tell you about:

Alzheimer's Disease or related Memory Problems/Family Caregiving

Physical Frailty

End of Life Decision Making

Suffering and Depression in Later Life

Other Aging-related Topics

* First Name:

* Last Name:

* Address:

* City:

* State:

* Zip:

County:

* Home Phone:

Fax:

* Email:

Race (optional):

Preferred Method of Contact: Email Phone Mail

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