---

Register as a Volunteer

Please register your interest in volunteering for clinical trials at Surrey Clinical Research Centre. The completion of this form will help in our selection process so please complete in as much detail as possible and we will get back to you. If you are currently unavailable, do register your interest in receiving information to join the volunteer recruitment database.

We are currently recruiting for the following clinical trials:

• Healthy Volunteers
• Males and Females of All Ages
• People with Sleeping Difficulties

Fields marked with an asterisk * are required and cannot be left blank.

Your name and contact details

Please give us your name and contact details, and ensure that you enter your phone number and your email address.

Title

Mr Mrs Ms Miss Dr Professor Reverend

Forename *

Surname *

Phone number *

Email address *

Address *

Your date of birth and gender

Date of birth dd12345678910111213141516171819202122232425262728293031mmmmJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberyyyy193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994

Please tell us your gender

Female

Male

Your height, weight and BMI

Use this section to tell us your height and weight and calculate your BMI.

NB: You must complete this section.

First choose your preferred units

Metric (cm/kg)

Imperial (feet/stones)

Now enter your height in metres and centimeters and your weight in kilogrammes and then click the Calculate BMI button.

Height

m 12 cm 123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899

Weight

kg 252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224

Now enter your height in feet and inches and your weight in stones and pounds and then click the Calculate BMI button.

Height

ft 12345678 in 01234567891011

Weight

stones 45678910111213141516171819202122232425262728293031323334 lb 12345678910111213

BMI

Smoking

Please tell us about your smoking history

I am currently a smoker

I am an ex-smoker

I have never smoked

How many cigarettes do you smoke per day? Please choose Fewer than 5 Between 5 and 10 Between 10 and 20 More than 20

How long ago did you give up smoking? Please choose Under six months ago Between six months and a year ago Between one and two years ago Between two and five years ago Between five and ten years ago Over ten years ago

Your medical details

Please tick all of the boxes below that apply to you. If you tick a box, you must provide details in the boxes that will appear.

I am currently taking medication

Please provide details

I am allergic to some medication

Please provide details

I have a medical condition that you should know about

Please provide details

I use contraceptives

Please provide details

I have asthma

Please provide details

My asthma is exercise induced

My asthma is present throughout the year

Please tell us what type of medication or inhalers you use to control your asthma

I have a sleep problem

Please provide details

Previous Clinical Trials

If you have taken part in a clinical trial before, please tick the box below and provide details, including dates.

Yes, I have previously taken part in clinical trials

Please provide details, including dates

Where did you hear about us?

Please chooseAldershot NewsBiotraxCapital GoldClassic FMCounty Sounds RadioDaily MailEagle RadioEvening StandardFacebookFriendGoogle SearchHampshire ChronicleHealth MagazineHeart RadioInternet Search EngineJob CentreJobs4StudentsLeafletLocal PaperLocal RadioLondon LiteMetroPortsmouth PaperSaga magazineSpotifySouthampton AdvertiserSurrey AdveristerSurrey TimesThe LadyTNT magazineTV InterviewUniversity of SurreyWebsiteWoking News & MailWord of mouthOther

Please tell us which search engine you used

Please tell us which local paper

Please tell us which local radio station

Please tell us which website

Please tell us where you heard about us

Declaration

I would like to join the Volunteer Database and I declare that any information provided by me with this form is accurate to the best of my knowledge and I understand that the Surrey Clinical Research Centre cannot be held responsible for any inaccurate information provided by me on this form. By submitting this form you agree to us contacting you with details about clinical trials. The information you submit will be held on paper and within the Surrey Clinical Research Centre electronic volunteer database. We may contact you about clinical trials by mail, email, phone or SMS. Please only tick the box if you understand and agree with the proposed use of the information as described above. The details you provide will be held in accordance with the Data Protection Act and will not be shared with a third party.