Allegheny River Stewardship Project Volunteer Registration Form
Thank you for your willingness to participate in the Allegheny River Stewardship Project. Your help will be valuable to this project. To help coordinate volunteer participation and projects please complete this entire form.
If you have further questions or need further information please contact us at
chec@pitt.edu
or check out the website at
www.chec.pitt.edu
Volunteer Participant Information
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First Name
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Last Name
*
Street Address
*
City
*
State
*
Zipcode
Township/Boro/Municipality
County
Gender
Male
Female
Other
Date of Birth
Race/Ethnicity
Caucasian
African American/Black
Hispanic
Asian
Native American
More than two races
Home Phone
Mobile Phone
Work Phone - (not necessary unless this is best way to get ahold of you)
Email Address
*
Student
Elementary
Middle School
High School
College
Graduate
Not Applicable
*
Will you fish the Community Fishing Days?
Yes
No
Don't Know
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Which Days Do You Plan to Fish?
May 10th Ford City-Rosston Eddy
May 31st Cheswick by Reliant Energy Plant
June 7th - Freeport at Buffalo Creek
June 14th Upper Allegheny
May 10th and May 31st
May 10th and June 7th
May 10th and June 14th
May 31st and June 7th
May 31st and June 14th
June 7th and June 14th
Three days
All Four
Don't Know
No Response
Are you interested in volunteering for other aspects of the project? (type in what you would be interested in)
All personal information that you may give on any form or on the volunteer sign up here that is associated with this project will be kept strictly confidential. Your name and any other identifying information will only be known by Dr. Volz and other members of the University of Pittsburgh research team. Should you not wish to further participate in this study at any time and without reason we are required to remove your name from our recurds subject to University of Pittsburgh Scientific Internal Reivew Board (IRB) regulations. After study conclusion you will be asked if you wish your name to be maintained in our records for potential follow up meetings and/or other research activity related to the project outcomes. We will only keep your information if you grant us written permission to do so.
Please indicate your answer to the following questions
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Would you like to be involved in the fishing activity for this project?
Yes
No
Don't Know
No Response
*
Would you like to be involved in other community meetings for this project?
Yes
No
Don't Know
No Response
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Would you like a presentation on the projct given to your group or organization?
Yes
No
Don't Know
No Response
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Would you like to be involved in one or more focus groups to discuss fishing, eating fish, pollution and the future of the Allegheny River?
Yes
No
Don't Know
No Response
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Would you like to be involved in community study or support activities?
Yes
No
Don't Know
No Response
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Would you consider giving samples of your hair, nails and/or urine to measure biomarkers of your toxic metal exposure?
Yes
No
Don't Know
No Response
*
Indicates Response Required
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