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UC Davis Neuromuscular Research Center Volunteer Registry
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Please complete the form below if you are interested in participating in research. Once you have completed this form you will be added to our Research Volunteer Registry. 

If you have any questions while filling out this form, please contact Evan at 916-734-3993

The UC Davis Health System takes protecting your information and privacy very seriously. Your information will not be released to research coordinators until you have initialed below. All information entered in the Research Volunteer Registry is sent to our servers via secure and encrypted means and is compliant with HIPAA standards. To learn more about UC Davis Health System's policies and compliance programs visit:

http://www.ucdmc.ucdavis.edu/compliance/guidance/privacy/
* must provide value


Please initial here before completing the rest of this form.
Are you interested in being contacted to participate in upcoming research studies?
* must provide value
Yes
No
Are you completing this form for your child?
Yes
No
Contact Information:
Contact First Name
Contact Last Name
Participant Information:
First Name
* must provide value
Last Name
* must provide value
Date of birth
* must provide value
   M-D-Y
Gender
Street
City
State
ZIP
Phone number
* must provide value
Include Area Code
Second phone number
Include Area Code
E-mail
Have you been diagnosed with a neuromuscular disease?
* must provide value
Yes
No
Would you be interested in participating as a typically developing volunteer/control?
Yes
No
Type of neuromuscular disease
if other, please complete describe below
Other Diagnosis:
Would you like to be contacted by a representative from our clinic to discuss receiving your medical care here at UC Davis?
Yes
No
Are you interested in hearing about how else you can support our research program (donation / gifts / volunteer)?
Yes
No
Notes/Comments:

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