Adult IHN Participant Registry Permission Form
This form is for adults, aged 19 years or older.
Thank you for your interest in participating in research at the Institute for Human Neuroscience (IHN) at Boys Town National Research Hospital (BTNRH). The purpose of the IHN Participant Registry is to help the Institute identify individuals who meet research criteria (e.g., age, gender, developmental condition, etc.) for various studies, and to be able to invite them to participate as they qualify for new studies.
1.
First Name
*
Please write your first name as it appears on your government-issued ID.
2.
Middle Name
3.
Last Name
*
Please write your last name as it appears on your government-issued ID.
4.
Email address
*
5.
Zip Code
*
6.
Cell Phone No.
*
7.
Prefered Contact Method
*
Phone Call
Text
Email
8.
How did you hear about us?
*
Social Media
Web Search
Flyer
Friend, Family member, or Coworker
Outreach Event (i.e., health fair)
Newspaper
Other