Participate in Twin Research

1. Please indicate your gender and your twin's gender by clicking the responses below:

   My gender: Male Female Other

   My twin's gender: Male Female Other

2. As far as you know, are you and your twin:

   Fraternal Identical

3. During your entire life, how close do you feel that you and your twin have been compared with your impression of closeness between ordinary siblings?

   Less close than ordinary siblings As close as ordinary siblings Somewhat closer than ordinary siblings Much closer than ordinary siblings

4. How far in miles do you live from your twin now?

   miles

5. How frequently do you and your twin get together now?

   Almost daily 1-4 times per week 1-3 times per month Occasionally during the year Less than once per year

6. Please give us your name, address, telephone number(s), and email address:

   First Name: *
   Last Name: *
   Number and Street:
   City, State, Zip
   Primary Phone: *	home phone cell phone work phone
   Alternate Phone:	home phone cell phone work phone
   Alternate Phone:	home phone cell phone work phone
   Email Address: *

7. Please provide your twin's name, current address, telephone number(s), and email address:

   First Name:
   Last Name:
   Number and Street:
   City, State, Zip
   Primary Phone:	home phone cell phone work phone
   Alternate Phone:	home phone cell phone work phone
   Alternate Phone:	home phone cell phone work phone
   Email Address:

8. May we contact your twin concerning joining this registry?

   No Yes

9. What is your date of birth?

   Month Day Year

10. What is your ethnic group?

    Black, non-Hispanic White, non-Hispanic Hispanic Asian Other

11. What is your marital status?

    Single Married Living together, not married Divorced Widowed

12. How many years of higher education have you completed?

13. Do you currently smoke cigarettes?

    No Yes Number smoked per day: Age you started smoking:

14. Are you a former smoker?

    No, I have never smoked Yes Number smoked per day: Age you started smoking: Age you quit smoking:

15. Where did you see/hear about SRI's twin registry (click on all that apply):

    Online (specify: search engine, online radio, other):
    SRI web site
    Newspaper (specify):
    Radio (which station?)
    Posters
    Other (specify):

Check here if you wish to participate in current research studies.

By clicking the 'submit' button below, you voluntarily consent to register with the Twin Research Registry at SRI International. By registering, you become eligible to participate in future twin research studies. You agree that you may be contacted by researchers about the possibility of participating in studies, but you will be under no obligation to participate in any study. All information gathered from this registration form will be held in confidence. You can remove your name from the registry at any time by contacting us at 1-800-SRI-TWIN (1-800-774-8946), or by post at SRI International, 333 Ravenswood Avenue, Menlo Park, California 94025, or via e-mail at: sri.twin@sri.com.

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