Participate in Research
 
We are always looking for participants to help us with our research. We’d be happy to collect your information, and contact you when a study matches your profile. Most studies offer cash incentive for participation.

The information we collect becomes part of our confidential database, strictly for the purpose of market research. We guarantee your information will only be used by Leap and will never be sold.

Questions with an (*) are required information.

If you have any questions, e-mail us at info@leapresearchinnovation.com.
 

First Name:*

Last Name: *

Date of Birth (mm/dd/yyyy):*

Phone:*

Cell Phone:

Address 1:*

Address 2:

Address 3:

City:*

State:*

Zip Code:*

County:*

Township:*

Email:*

Gender:* Female Male

How much of your household's grocery shopping do you typically do?* Most or all of it
About half of it
Less than half of it
None

Ethnic Origin:* Asian
Black/African American
Caucasian/White
Hispanic/Latino
Mixed Race
Native American
Other
Would rather not say

Residence:* Own your home
Rent your home
Live with parent/relative

Highest Level of Education:* 2 Year Degree
4 Year Degree
High School Graduate
Post-Graduate Degree
Some College
Some High School

What is your occupation?*

What is the industry of your current employer? (healthcare, food manufacturer, restaurant, construction, etc.)

Annual Household Income:* Below $29,999
Between $30,000 and $49,999
Between $50,000 and $74,999
Between $75,000 and $99,999
Over $100,000

Marital Status:* Married/Co-habitating
Separated/Divorced
Single/Never Married
Widowed

Spouse's Name:

Spouse's Date of Birth (mm/dd/yyyy):

Do you have children under the age of 18 living at home?* Yes No

What is your first child's date of birth? (mm/dd/yyyy)

What is your second child's date of birth? (mm/dd/yyyy)

What is your third child's date of birth? (mm/dd/yyyy)

What is your fourth child's date of birth? (mm/dd/yyyy)

What is your fifth child's date of birth? (mm/dd/yyyy)

How did you hear about the opportunity to participate in Leap's research studies?*
Card with Leap's information
Facebook
Friend or family member
I was searching for market research opportunities
Other (please specify below):
Poster (please indicate poster's location below):

If Other, please specify:

If Poster, please specify location below:
Thank you!
 
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