Research Registry

Pledge Information

What are you signing up for? Check at least one box

I pledge to donate my brain to research after my deathI am interested in participating in clinical research

Would you like to make your brain pledge public information?

Basic Information

Title

First Name

Middle Name

Last Name

Suffix

Country

Address

City

State/Province

Use abbreviated state name (Ex. New York = NY)

Postal Code

Phone Number

Confirm Email

Date of Birth (MM/DD/YYYY)

Race

Sex

Military Service

Military Branch

Military Status - Pre or Post 9/11?

If your service ENDED before 9/11/2001, select "Pre 9/11"

Exposure Information

This section asks about your history of brain trauma exposure. Complete this section to the best of your ability regarding your knowledge of the patient's brain injury history. You do not need to have experienced brain trauma in order to sign up for the Clinical Research Registry or Brain Donation Registry. We encourage you to sign up regardless of your brain trauma history.

Primary Exposure

Other - Primary Exposure

Years of Primary Exposure

If Primary Exposure was a sport, what is the highest level reached of the primary sport you played?

Secondary Exposure

How many concussions would you estimate you have suffered?

Referral Information

How did you hear about us?

If you selected other, how did you hear about us?

If you were referred by a military-related organization(s), which organization(s)? Select all that apply:

If you were referred by a military-related organization not listed here, which organization referred you?

If you were referred to sign up by a friend/family member, who referred you?

Contact Information