First Name*

Last Name*

Preferred Method of Contact:
EmailPhoneBoth/Either

Email Address*

Phone Number*

Year of Birth

Current Gender Identity
MaleFemalePrefer to Self-IdentifyPrefer Not to Answer

How do you want to be involved in research?
I would like to volunteer to be a participant in a research study. For more information about participating in clinical research trials, please visit www.itstartswithme.caI would like to volunteer to be on a research team to help plan research projectsOther

What other ways would you like to be involved in research?*

What type of research study would you be interested in learning more about? Check all that apply
Heart DiseaseStrokeCancerDiabetesKidney DiseaseDementiaInfectious DiseaseMental HealthLifestyle Factors (e.g., Physical Activity, Diet, or Smoking)Aging and Older Adult Research

Are there other types of research study would you be interested in learning more about?

Are you willing to be involved in research virtually? (e.g., Zoom/Teams meetings, over the phone, communicating through email?
YesNo

In which Health Zone do you live?
Health Zone 1 (Bouctouche, Moncton, Dieppe, and Shediac areas)Health Zone 2 (Sussex, Saint John, and St. Stephen areas)Health Zone 3 (Fredericton, Perth-Andover, Cambridge Narrows, and Woodstock areasHealth Zone 4 (Edmundston, Grand Falls, and Kedgwick areas)Health Zone 5 (Campbellton and Dalhousie areas)Health Zone 6 (Bathurst, Caraquet and Tracadie areas)Health Zone 7 (Neguac and Miramichi areas)

Are you willing to travel to another health zone to be involved in research?
YesNo

If you would like to volunteer for a research study, would you agree to share your contact information with Horizon researchers so that they may contact you directly?
YesNo