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To become part of the MyAlliance network and receive MyAlliance Monday Highlights, please provide the information below and click submit.
We appreciate your interest in learning more about the research studies and services we offer at the University of Kansas Alzheimer's Disease Research Center. Connecting with us is an important step toward us finding better ways to prevent and treat Alzheimer's disease and other dementias. Complete the form below with your contact information and research interests and a member of our team will contact you to discuss further. (Research opportunities are available for both people with and without diagnosed memory changes.) Please note that the information you provide here is collected and kept as part of our process to best match you to the services and studies offered at the center.
Today M-D-Y
What types of research studies are you interested in?
What other type(s) of research are you interested in?
Are you interested in a specific research study that you recently became aware of?
Yes No
What is the name of the research study you are interested in?
What most recently caused you to reach out to the KU Alzheimer's Disease Research Center with an interest in participating in research?
Family or Friend Health Care Professional (MD, RN, etc.) Newspaper, Magazine, or Podcast TV or Radio Website/Internet Social Media (Facebook, Twitter, etc.) Brochure, Flyer, or Poster Public Presentation/Event (In-person) Mail/Letter or email MyAlliance Sponsor portal Webinar
Would you like yourself or a loved one to be considered for clinical research at the KU Alzheimer's Disease Research Center?
Self Loved one
What is your relationship to the person on whose behalf you are filling out this form?
spouse child parent sibling other
Please specify your relationship
Your name
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Your first and last name
Your email
Your Phone Number
Your primary speaking language(s)
Your other primary speaking language
Choose which resources you prefer to receive
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Resources for brain health and dementia caregiving, research, and prevention Resources as above, but for those diagnosed with a dementia
How did you learn about MyAlliance?
Attended a virtual or live education program At an ADRC or community event/meeting From a friend or family member Through research participation From a health care professional or ADRC staff member Social media Received a text message TV, radio, podcast or newspaper Brochure, poster, flyer Received a mailing or email Juntos Other
Want to be informed of ADRC giving opportunities?
yes please no thank you
First & Last Name
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If you are completing this on behalf of someone else, please list their name here.
If you are completing this on behalf of someone else, please list their preferred name here.
Today M-D-Y If you are completing this on behalf of someone else, please list their date of birth here.
View equation If you are completing this on behalf of someone else, please list your loved one's email here. If you do not want us to contact them at all (and only contact you) please leave this blank.
If you are completing this on behalf of someone else, please list your loved one's phone number here.
If you are completing this on behalf of someone else, please list your loved one's zip code here.
Primary speaking language of your loved one
Please specify the other primary speaking language
Memory Status Questions
The following questions are about the memory status of person on whose behalf you are calling. If you would like to be considered for research, answer the questions for yourself, otherwise answer the questions with your loved one's information.
Do you feel that you (they) are experiencing any memory or thinking changes?
Yes No Maybe/I don't know
Please indicate what changes in memory, thinking or behavior are being experienced, if any. (click all that apply)
Decreased or poor judgment
Less interest in hobbies/activities
Repeating the same things over and over (questions, stories, or statements)
Trouble learning how to use a tool appliance or gadget (e.g. computer, microwave, remote control)
Confusion with time or place
Difficulty handling financial affairs? (e.g., balancing checkbook or paying bills)
Trouble remembering appointments
Daily problems with memory or difficulty completing familiar task
Decreased or poor judgment
Less interest in hobbies/activities
Repeating the same things over and over (questions, stories, or statements)
Trouble learning how to use a tool appliance or gadget (e.g. computer, microwave, remote control)
Confusion with time or place
Difficulty handling financial affairs? (e.g., balancing checkbook or paying bills)
Trouble remembering appointments
Daily problems with memory or difficulty completing familiar task
Have these concerns been mentioned to a doctor?
Yes No
Have you (they) been diagnosed with a memory impairment?
Yes No
Are you (they) currently taking prescribed memory medications?
Yes No
Are you (they) interested in our Down Syndrome studies?
Yes No
Other notes, comments or concerns
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Thank you! A member of our research team will contact you as soon as possible to discuss the current research opportunities available.
**Please note: Many of our studies limit participants to active participation in only one study at a time. If you are already enrolled in one of our research studies, we encourage you to first contact your study coordinator to discuss further, prior to completing this form. Thank you for understanding.**
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