LHIDS Registration

Questions with a [*] require an answer.

Thank you for your interest in participating. Please fill out the following information and the survey will be mailed to you.

[*] Full name of contact person/caregiver:

[*] Contact person address:

[*] Contact person telephone number:

Alternate contact number:

[*] Contact person email address:

[*] Full name of person with an intellectual disability:

Please Note: The adult with intellectual disabilities involved in the study must be at least 18 years of age and residing in the United States to participate.