Registration Form

This form is used to register all interested participants in the Alzheimer Disease & Related Dementia Research Study "Puipui Malu Manatu".  Applicants must be 50 years or above, of Samoan ancestry, be able to speak Samoan or English and willing to contribute a blood sample. By registering you are agreeing to be contacted by the Office at a later date to take part in the study. Please contact the AS Community Cancer Coalition at 699-0110 for questions and more information. Thank you! 

O lenei pepa resitara e faaagaaga mo i latou uma o loo fia auai i le su'esu'ega o le "Puipui Malu Manatu." E agava'a i latou uma ua 50 tausaga o le soifua pe sili atu, o se e iai oga tupuaga i Samoa, ia iloa tautala ma malamalama i le fa'aSamoa po o le faaperetania ma e malie e tui lona toto mo le suesuega i se taimi o i luma. O lou faatumuina o lenei pepa, e te malie e faafesootai atu oe e le ofisa i se taimi o i luma. Fa'afesootai mai le Ofisa o le Kanesa i le 699-0110 mo ni fesili. Faafetai. 

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* 1. First Name/Igoa/Suafa

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* 2. Last Name/Fa'aiu

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* 5. What is your ethnicity?
O le a lou faasinomaga/ituaiga tagata?

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* 6. What is your gender?
O le a le itupā?

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* 7. What is your phone number?
O le a lau numera telefoni?

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* 8. What is your email address?
O le a lau imeli?

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