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Ideas + Technology for Healthy Living
[•] About AgeLab / Volunteer
 
 

Register to Volunteer: AgeLab is looking for volunteers who would like to drive Miss Daisy (our driving simulator set up in a VW Beetle), or participate in other AgeLab experiments. If you are able to come to MIT in Cambridge to take part, please fill out the following:

Name
First Name Last Name
 
E-Mail Address
yourname@isp.com
   
Telephone
Day Telephone Evening Telephone Cellular Telephone
   
Preferred Method of Contact
Day Telephone Cellular Telephone Evening Telephone Via E-Mail
   
Mailing address
Street: (ex 123 Johns Lane, #2)    
City State Zip Code
     

More about you:

   
Birthday /
 
Gender Male    Female
   
Do you have a valid drivers license? Yes   No
   
How often do you drive a car or other motor vehicle?







   
Over the last year, how many miles did you drive?









 
How often do you use a cellular phone?







 
How often do you use a computer?








 
Please decribe the highest level of formal education you have completed:








 
In the past five years, how many times as a driver have you been in a police reported accident?
 
How would you charecterize your overall health?






 
Do you typically get motion sick? Yes   No
 
If yes, where? (press Ctrl for multiple selections)


 


Thank you for your willingness to participate in AgeLab's research projects. The information provided in this form will be kept strictly confidential and will not be distributed to any outside agencies. Would you like to receive a copy of this message? yes no

 
 
 
 
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