Register as a Volunteer

Please register your interest in participating 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 participant recruitment database. You will need to register with us online to be able to take part in a clinical study.

You must be aged 18 and over to register for clinical trials.

Symbols (such as '&') will not be accepted, please do not use these when completing the registration.

Application and Eligibility

What would you like to apply for? *

Eligible to work in the UK? *

Yes

You must be eligible to work in the UK to register

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

Forename *

Middle Name

Surname *

Which phone number would you prefer us to call you on?

Mobile phone number

Home phone number

Mobile phone number *

Home phone number

Email Address *

Address *

City *

County *

Post Code *

Country *

You must be eligible to work in the UK to register

Your date of birth and gender

Date of birth *

Day

Month

Year

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.

Height *

Weight *

Smoking

How many cigarettes do you smoke per day?

Contraception

Please provide details of your contraception

Your medical details

Do you have any medical conditions?

Are you currently taking any medications? (If yes please list below)

Do you have any allergies?

Do you have any diagnosed sleep problems? *

Vaccinations

Please select any of the vaccinations you have received below

I have received:

Hepatitis B vaccination

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

Previous trials

Please provide details, including dates

Where did you hear about us?

Where did you hear about us? *

If other please specify

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

How we use your personal information

Any information you provide which can identify you will be added to our Volunteer Database so that we can contact you to assess your suitability to take part in our clinical trials. All your personal information will be treated as confidential by the Surrey Clinical Research Centre and will be held and processed under secure conditions in accordance with UK and EU data protection laws. We may contact you about clinical trials by mail, email phone or SMS. If you do not wish to receive details about our services you can opt-out at any time by sending an email to crc-recruitment@surrey.ac.uk and your account will be deactivated and your record will be removed from the database.

If you take part in a clinical trial with us we may update your record with significant information that emerges from the study (e.g. medical diagnoses or medical history that is likely to affect eligibility for future trials).

You can update us with any changes to your details by emailing crc-recruitment@surrey.ac.uk.

You can find out more information regarding data protection by reading our privacy notice.

I declare that the information provided by me is accurate to the best of my knowledge. I am also giving consent to the Surrey Clinical Research Centre to process my application to join the volunteer database and for entry into clinical trials.

Declaration *

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This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

You must be aged 18 and over to register for clinical trials.

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