Participate in a Hearing Research Study Page Content Please fill out the following form if you would like to participate in a hearing research study. Volunteer Information Volunteer Name * Volunteer Date of Birth* Parent/Guardian Name (if Volunteer is a child 18 or younger) Address Information Address Address Line 2 City State State AL - Alabama AK - Alaska AZ - Arizona AR - Arkansas CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida GA - Georgia HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VT - Vermont VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming Zip Code Contact Information Primary Phone * Home Cell Work Secondary Phone Home Cell Work Email Address * HEARING & COMMUNICATION INFORMATION Hearing Status* Normal Hearing Concerns Cochlear Implant History of Loud Noise Exposure Yes No Balance (Vestibular) Concerns Yes No Speech & Language Concerns Yes No Primary Language * English Spanish Other Secondary Language Spanish English Other DEMOGRAPHICS/ADDITIONAL INFORMATION Volunteer Gender Male Female Volunteer Ethnicity (optional) Hispanic/Latino Not Hispanic/Latino Volunteer Race (optional)Select one or more: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White What is the best way to contact you? -- select -- Home Phone Cell Phone Work Phone Email When does your schedule allow you to come to BTNRH? Days Evenings (After 5PM) Saturdays If filling this out for a child, what school district 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, including the information above, and any hearing, balance, cochlear implant, and speech and language test results and information obtained by Boys Town National Research Hospital staff. I agree to be contacted about research studies being conducted at Boys Town National Research Hospital. I cannot agree on behalf of any other adults in my family ages 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. Thank you for your interest in the Boys Town National Research Hospital Research Center and participating in research studies. We will review your information and contact you as soon as possible. We apologize, but an error has occured during processing of this form. Please try again later.