There are many opportunities available for cooperating scientists and institutions to become involved. From tissue and sample collection, to dual performance of laboratory tests and procedures, corroboration of findings, to clinical trials - there is much to get involved with and much that you may be able to contribute to. Becoming involved as a collaborating scientist, requires your physical and direct participation in The Crohn's Disease Initiative's goals and objectives. We encourage other scientists, physicians, and others that can contribute in other ways to join us as a member.

Even if you know the investigators on this project and have spoken to them about your participation, you MUST complete the form below. It is the only way to become integrated into the system.

YOUR INFORMATION
Your First Name:
Your Last Name:
Institutional Affiliation:
Department:
Address:
Address:
City:
State:	Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming -- CANADA - - Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Nunavut Northwest Territories Ontario Prince Edward Island Quebec Saskatchewan Yukon Other
Other State: (If other than a US or Canadian State/Province, please select "Other" (listed last in dropdown box), and enter your State or equivalent at right.)
Your Zip or Postal Code:
Your Country:	United States Andorra United Arab Emirates Afghanistan Antigua and Barbuda Anguilla Albania Armenia Netherlands Antilles Angola Antarctica Argentina American Samoa Austria Australia Aruba Azerbaijan Bosnia and Herzegovina Barbados Bangladesh Belgium Burkina Faso Bulgaria Bahrain Burundi Benin Bermuda Brunei Darussalam Bolivia Brazil Bahamas Bhutan Bouvet Island Botswana Belarus Belize Canada Cocos (Keeling) Islands Central African Republic Congo Switzerland Cote D'Ivoire (Ivory Coast) Cook Islands Chile Cameroon China Colombia Costa Rica Czechoslovakia (former) Cuba Cape Verde Christmas Island Cyprus Czech Republic Germany Djibouti Denmark Dominica Dominican Republic Algeria Ecuador England Estonia Egypt Western Sahara Eritrea Spain Ethiopia Finland Fiji Falkland Islands (Malvinas) Micronesia Faroe Islands France France, Metropolitan Gabon Great Britain (UK) Grenada Georgia French Guiana Ghana Gibraltar Greenland Gambia Guinea Guadeloupe Equatorial Guinea Greece S. Georgia and S. Sandwich Isls. Guatemala Guam Guinea-Bissau Guyana Hong Kong Heard and McDonald Islands Honduras Croatia (Hrvatska) Haiti Hungary Indonesia Ireland Northern Ireland Israel India British Indian Ocean Territory Iraq Iran Iceland Italy Jamaica Jordan Japan Kenya Kyrgyzstan Cambodia Kiribati Comoros Saint Kitts and Nevis Korea (North) Korea (South) Kuwait Cayman Islands Kazakhstan Laos Lebanon Saint Lucia Liechtenstein Sri Lanka Liberia Lesotho Lithuania Luxembourg Latvia Libya Morocco Monaco Moldova Madagascar Marshall Islands Macedonia Mali Myanmar Mongolia Macau Northern Mariana Islands Martinique Mauritania Montserrat Malta Mauritius Maldives Malawi Mexico Malaysia Mozambique Namibia New Caledonia Niger Norfolk Island Nigeria Nicaragua Netherlands Norway Nepal Nauru Neutral Zone Niue New Zealand (Aotearoa) Oman Panama Peru French Polynesia Papua New Guinea Philippines Pakistan Poland St. Pierre and Miquelon Pitcairn Puerto Rico Portugal Palau Paraguay Qatar Reunion Romania Russian Federation Rwanda Saudi Arabia Scotland Solomon Islands Seychelles Sudan Sweden Singapore St. Helena Slovenia Svalbard and Jan Mayen Islands Slovak Republic Sierra Leone San Marino Senegal Somalia Suriname Sao Tome and Principe USSR (former) El Salvador Syria Swaziland Turks and Caicos Islands Chad French Southern Territories Togo Thailand Tajikistan Tokelau Turkmenistan Tunisia Tonga East Timor Turkey Trinidad and Tobago Tuvalu Taiwan Tanzania Ukraine Uganda United Kingdom US Minor Outlying Islands United States Uruguay Uzbekistan Vatican City State (Holy See) Saint Vincent and the Grenadines Venezuela Virgin Islands (British) Virgin Islands (U.S.) Viet Nam Vanuatu Wales Wallis and Futuna Islands Samoa Yemen Mayotte Yugoslavia South Africa Zambia Zaire Zimbabwe
Phone Number: (Format:123-456-7891)
Cell Phone Number:
Your Email address:
Confirm your Email address:
YOUR INTERESTS
Your Institutional Position:
Degrees:
Describe your desired collaboration in the program:
Describe any conflict of interests: A conflict of interest is defined as any participation in any company that could potentially benefit from the outcome or failure of this program and includes holding of stocks, consulting, partnerships, ownerships, etc)
Will your collaboration or participation in the program require any financial support from The Crohn's Disease Initiative?:	YES   NO
Do you have the financial resources to support your participation and collaboration in The Crohn's Disease Initiative?	YES   NO
USERNAME & PASSWORD
In order to gain access to certain portions of The Crohn's Disease Initiative website, to post questions and see answers in our forum and blogs, you need to provide a username (userid) and password. As a collaborating scientist, you will have the ability to intract with patients as well as other scientists of the CDI. As such, we suggest an identifiable Username rather than one which keeps your identity anonymous.
Username:
Password:
I have read and understand the User Agreement and Privacy policy of thecrohnsdiseaseinitiative.com and agree to abide by the terms and conditions of said Agreements and Policies. This document will not be "signed" in the sense of a traditional paper document. To verify the contents of this form, the signatory must enter any combination of alpha/numeric characters that has been specifically adopted to serve the function of their legal signature. Learn More Pursuant to the Federal Electronic Signatures in Global and National Commerce Act (Pub.L.106-229, June 30, 2000) and applicable state laws, I consent to The Crohn's Disease Initiative's use and reliance on my electronic signature to verify the information that I have provided herein.
Signature:     (do not alter the date field)
Your IP address is: 38.107.179.210