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Rush Memory Clinic Data Repository Interest Form

Name:



Address:





Caregiver Information: Optional


Type of Residence:


With what racial/ethnic group do you most closely identify yourself:


Are you of Spanish/Hispanic origin?


In what language(s) are you fluent (reading, writing, speaking)?Check all that apply


Years of Education

Elementary/Junior High:
High School:
College:
Graduate School:

How did you hear about us?



What type of research study would you like to be contacted about


Contact Person:



Please select an item below to indicate you level of interest in participating in the Memory Clinic Data Repository: (required)