CHB-CONNECT   Research Volunteer Registry   
  
Register a Research Study Volunteer
* denotes a required field
Please provide information about the person who you are registering as a research volunteer.
First Name: * Last Name: *
Gender: *       Date of Birth mm/dd/yyyy: *   click here to select a date
Your relationship to this volunteer: *     Self     Father     Mother     Guardian
Which areas are you interested in hearing about? *
Medical Area of Interest #1:
Medical Area of Interest #2:
Medical Area of Interest #3:
Medical Area of Interest #4:
Check here if you are interested in being contacted for healthy volunteer studies.
  
What is the contact information for this Volunteer?
First Name: * Last Name: *
Address:
  
City:     State:     Zip
Home Phone: Cell Phone:
Email Address:
In what ways would you like to be contacted?*
any mode, no preference     Mail     Email     Telephone     Cell Phone    
  
How did you hear about this registry?
Newspaper advertisement Current patient or family My child's pediatrician ClinicalTrials.gov
Children's News Pediatric Views Small Talk CME event
Children's Hospital Intranet
  
       
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