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Please enter your information to be notified of an upcoming clinical study that involves free travel to Mexico or Guatemala. Your information will not be shared or distributed. This information will only be used for the strict purpose of contacting you with updates about this opportunity.

Name


First	MI	Last

Gender

Male Female

Address


City	State	Zip Code

Primary Phone

	Alternate Phone
123-456-7890		123-456-7890

E-mail

Which country are you interested
in traveling to?

Are you able to travel to Mexico or Guatemala for at least seven days between August 2009 - December 2010?

Yes No

If yes, what month are you most likely to travel?
Anticipated Arrival Date
Anticipated Departure Date
Do you already have confirmed travel plans?	Yes No

As part of this study, we will also have group travel with pre-planned itineraries. Would you be interested in traveling as part of an organized group?
Yes No Maybe Already In A Group

Do you know of any groups (volunteer or aid organizations, churches, schools, clubs, etc.) that would be interested in participating in this study?

Organization Name

Address


City	State	Zip Code

Group Leader


First	Last

Contact Email

Contact Phone

123-456-7890

If you were referred, please enter their name and email.

Name	First	MI	Last

E-mail

If you have a three-digit promotional code, please enter it here:

Comments/Questions?