STEPS2 Interest Form
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Thank you for you interest in participating in STEPS2, an online health education program hosted by the CUNY School of Public Health. For more information, see here:  https://cunyisph.org/steps2-study/

To be eligible to participate, you MUST:
  1. Live in New York State
  2. Be 16 to 27 year old 
  3. Have an intellectual or developmental disability
If you'd like to be contacted about joining this study, please complete this form. The information you provide will remain confidential.

NOTE: If you are filling out the form on behalf of more than one individual, please submit one form per person. Also, participants who have completed the program may not repeat the program, and should therefore refrain from filling out this form. 

THOSE WHO MISREPRESENT THEMSELVES IN ORDER TO APPEAR ELIGIBLE WILL BE SWIFTLY IDENTIFIED AND EXCLUDED FROM PARTICIPATION AND NOT RECEIVE PAYMENT. 
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First Name of Potential Participant  *
Last Name of Potential Participant *
First Name of Person Completing Form (If Someone Other Than Potential Participant)
Last Name of Person Completing Form (If Someone Other Than Potential Participant)
Relationship to Potential Participant (If Completing Form on Their Behalf) 
Primary Phone Number  *
Secondary Phone Number
Preferred Email Address *
How did you find out about STEPS2? (If you were given a referral code, please also include it here).
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