Jefferson College of Health Professions - Center for Applied Research on Aging and Health

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Registry Form for Project COPE

This registration form has been provided to allow you to receive information regarding participation in Project COPE, a study sponsored by the Pennsylvania State Department of Health as part of the Pennsylvania Center of Excellence in Alzheimer’s Disease of the Farber Institute for Neurosciences. All information given will be maintained in a secure database that is accessible only by the Center for Applied Research on Aging and Health (CARAH) personnel. All participation in all of the Center’s research projects is strictly voluntary. The information that you provide consists of your address and answers to questions about your caregiving situtation.

All research participants receive payment for interviews conducted in their home. There is no cost to participating in any part of the program. Participation does not affect services received through other agencies.

Once registered in our research volunteer database, you may remove yourself from the registry at any time. You may also change your profile information at any time. To change information, Click on “Contact Us” located in the left hand column on any page, enter “Changes to Registry” as the subject of an email and send it to the address provided. Please include your name and any additions and/or modifications to your information in the text of the email. Or you can write “Unsubscribe” as the title of the email. You may unsubscribe when you receive information about a study by replying and typing “unsubscribe” as the subject of the email.

In order for us to best help you, please answer the following questions.

* Required fields

Please indicate your gender: Male Female

* Date of Birth:

Have you ever participated in any of our research projects before? Yes No

Are you caring for someone with dementia or a related memory problem? Yes No

(If yes) Do you live with the person you are caring for? Yes No

* First Name:

* Last Name:

* Address:

* City:

* State:

* Zip:

County:

* Home Phone:

Fax:

* Email:

Race (optional):

Preferred Method of Contact: Email Phone Mail

The Thomas Jefferson University web site, its contents and programs, is provided for informational and educational purposes only and is not intended as medical advice nor is it intended to create any physician-patient relationship. Please remember that this information should not substitute for a visit or a consultation with a health care provider. The views or opinions expressed in the resources provided do not necessarily reflect those of Thomas Jefferson University, Thomas Jefferson University Hospital, or the Jefferson Health System or staff. Please read our Privacy Statement.

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