BrainCheck Research Study Registration

Please fill out the form to let us know that you are interested in participating in our research study. This information will be kept private and will only be used to contact you for the study.

* Required Fields

First Name *

Last Name *

Sex *

Date of Birth *

Are you of Hispanic, Latino/a/x, or of Spanish origin?

Which of the following racial designations do you identify with? More than one choice is acceptable.

What is your highest level of education? *

Phone number *

Email *

Zip Code *