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Rush Memory Clinic Data Repository Interest Form



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:
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)