Research Participant Application Form First name* Last name* Preferred Method of Contact: EmailPhone Email address* Phone number* Year of Birth Gender: MaleFemaleOtherPrefer 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 my time on a committee that plans research projects in my communityOther What type of research study would you be interested in learning more about? Check all that apply Heart DiseaseStrokeCancerDiabetesKidney DiseaseDementiaInfectious Disease Are there other types of research study would you be interested in learning more about? To which of the following regions would you travel to participate in research? Check all that apply. WoodstockFrederictonSaint JohnMonctonMiramichi 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