Skip Ribbon Commands
Skip to main content
Skip Navigation LinksBoys Town National Research Hospital > Research > Participate in a Research Study Sign-Up Form

Participate in a Research Study Sign-Up Form

Your Name*

Volunteer Name (if filling out for someone other than yourself)

Volunteer Date of Birth

Select a date from the calendar.

Address

City

State

Zip/Postal Code

Home Phone

Cell Phone

Work Phone

E-mail*

Volunteer Gender*

Volunteer Hearing Status*

Volunteer Ethnicity (optional)

Volunteer Race (optional)





What is the Primary Language spoken in your home?

What is the best way to contact you?

When does your schedule allow you to come to BTNRH?



If filling this out for a child, what school districts does the child attend?

If we are unable to contact you, is there someone (family or friend) with whom we may leave a message?  If yes, please provide the name and phone number of that person:

By checking this box, I agree to have my name and/or my children’s names added to the Boys Town National Research Hospital volunteer database. This includes the information above, any hearing test results and cochlear implant information obtained by the Boys Town National Research Hospital staff. I cannot agree on behalf of any other adults in my family 19 years or older. I understand that I may refuse to participate in any study and that I may remove my name (or my children’s names) from the database at any time. There is no penalty for non-participation or withdrawal. My refusal will not affect in any way the services I receive now or in the future from Boys Town Hospital or any associated clinics.