Research Participant Registration Form

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1. Name

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2. Zip Code

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3. Cell Number - Enter 10 digits (no dashes, periods or parentheses)

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4. Email

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5. Age

18-20

21-30

31-40

41-50

51-60

61-70

71+

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6. Gender

Male

Female

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7. Race

African American

Asian/Pacific Islander

Caucasian

Latino

Other (please specify)

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8. Would you like to participate in our online surveys?

Yes

No

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9. Do you agree to receive email and text notifications about upcoming studies?

Yes

No