Research Participation Application Form *indicates a mandatory field 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.ca I would like to volunteer to be on a research team to help plan research projects (i.e., as a patient/public partner) I would like to learn about research happening in New Brunswick (i.e., through newsletters or quarterly updates) Other If you selected “Other,” what other ways would you like to be involved in research? Would you like to learn about research happening across the Maritimes by receiving occasional research partnership opportunities from the Maritime SPOR SUPPORT Unit (MSSU), such as projects that involve people with lived experience from New Brunswick and other Maritime provinces? YesNo What types of research studies would you be interested in learning more about? Check all that apply. Heart Disease Stroke Cancer Diabetes Kidney Disease Dementia Infectious Disease Mental Health Lifestyle Factors (e.g., Physical Activity, Diet, or Smoking) Aging and Older Adult Research List any other types of research studies you would be interested in learning more about: Are you willing to be involved in research virtually (e.g., through Zoom or Teams meetings, over the phone, or by communicating through email)? YesNo In which Health Zone do you live? —Please choose an option—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 areas)Health 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 have any questions about being involved in the “A Cure is on the Horizon” Research Registry, please reach out to Sarah Bridges, the registry manager, at Sarah.Bridges@HorizonNB.ca.