* Required Fields 

First Name: *

Last Name: *

State (CA only): *

City (must be within 25 miles of Berkeley)*

Email: *

Phone: *

Is it o.k. to call you at this number? 

  Yes   No, contact by email only

Age: *

Height: *

--Select-- 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6' 6'1" 6'2" 6'3" 6'4" 6'5"

Weight (pounds):*

Eye Color:

--None-- Blue Brown Gray Green Hazel

Hair Color:

--None-- Black Blonde Red Brown Light Brown

Are you currently employed?:*

--None-- Full Time Not Employed Part Time Student

Profession: 

Level of Education Completed: 

Name of college attended, if any:

Are you a citizen of the United States?:*

  Yes  No

How did you hear about us?: 

Are you able to make a commitment to donate at least once a week at our Berkeley office, for one year? (You must visit during lab hours, weekdays, 8:00 a.m. to 4:00 p.m):*

Yes No 

FAMILY AND MEDICAL INFORMATION

Ethnic Background/Country of Origin, Mother: 

Ethnic Background/Country of Origin, Father:  

Are you in touch with both of your biological parents?:*

 Yes No  

Have you, or has anyone in your family, including your aunts, uncles, and grandparents, ever had any of the following?:

Diabetes (Type 1 or Type 2)

Yes      No

Heart Disease, Heart    Attack, or High Blood Pressure

Yes     No

Cancer

Yes     No

Mental Illness (Bi-Polar, Schizophrenia, Depression, etc.)

Yes     No

Genetic Diseases (Alzheimer's, Sickle Cell Carrier, etc.)

Yes     No

Birth Defects (spina bifida, cleft palate, heart malformation, etc.)

Yes     No

Alcoholism or Substance Abuse

Yes     No

Do you drink alcohol?

Yes No

If so, how many drinks per week?: 

Have your sexual partners in the past five years been:

Men     Women    Both

Do you have any additional comments?