Join Our Panel
   

Thanks for considering joining the PAR Research Panel.  From time to time participants will receive offers to participate in research projects of various sorts.  Many of the projects offer compensation for participation. Incentives vary.  We promise you'll find them all interesting! 

First Name

Last Name

Street Address

Address (cont.)

City

State

Zip

Home Phone

E-mail


Age

Under 18

18-24

25-34

35-44

45-54

55 or over


Gender

Male

Female


Race

African-American

American Indian, Eskimo

Asian, Pacific Islander

Caucasian

Hispanic

Other

Unknown/Refused


Education

Less than high school

High school diploma/GED

Some college, no degree

College graduate

Unknown/Refused

   
Occupation

Married  (If Yes, please enter Spouse information)

Yes

No


Spouse Name

Spouse Age

Under 18

18-24

25-34

35-44

45-54

55 or over


Spouse Education

Less than high school

High school diploma/GED

Some college, no degree

College graduate

Unknown/Refused


Spouse Occupation

Children at home

Yes

No


Child 1 Year of Birth

Child 1 Gender

Male

Female

   
Child 2 Year of Birth

Child 2 Gender

Male

Female


Child 3 Year of Birth

Child 3 Gender

Male

Female


Child 4 Year of Birth

Child 4 Gender

Male

Female


Activities/Hobbies

Arts/Crafts

Archery

Basketball

Baseball

Bowling

Computers

Electronics

Football

Reading

Soccer

Travel

Unknown/Refused


Pets

Yes (Specify)

No



Occasionally we need people with specific health issues.  Which of the following health conditions apply to you or anyone in your immediate household? (check all that apply)

No health concerns/problems

Allergies

Asthma/COPD

Cancer

Diabetes

Heart condition

High cholesterol

Hormone Replacement Therapy

Hypertension/high blood pressure

Mental health issues

Sleep disorder/sleep apnea

Don't know/Refused

Other (specify)


Favorite radio station?

#1

#2

#3


Favorite food?

Favorite beverage?


 
     
 
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