Healthy Volunteer Application FormStep 1 of 140%OK, let's get you startedPlease confirm your email address(Required) What is your full name?(Required) First name Last name Your preferred phone number(Required)(Please enter a valid 11-digit phone number starting with a '0')Comms Agreement I would like to sign up to FluCamp’s mailing listT&Cs Agreement(Required) I have read and agreed to the Terms and Conditions and Privacy Policy(Required)To continue, please make sure you check this boxWhen were you born? Date Of Birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please tell us your genderGender(Required) Male Female Non-binary OtherOther Gender(Required)Which of the following best describes you?Which of the following best describes you?(Required) White (British, Irish, or any other white background) Multiple ethnic groups (e.g., White and Black Caribbean, White and Asian, etc.) Asian or Asian British (e.g., Indian, Pakistani, Bangladeshi, Chinese, etc.) Black, African, Caribbean, or Black British OtherOther Ethnicity(Required)Which screening centre would you prefer?We have two screening hubs located across the UK for you to choose from.As a thank you for your time, you'll receive £40 for your first screening visit.Location Preference(Required) London ManchesterWould you like to use a referral code?If one of your friends referred you, make sure to ask them for their volunteer ID number. When you attend a trial, your friend will receive £500 as a thank you for referring you. If you don't have a code, no worries, simply continue on to the next step.Referral codeIf you have asthma, please head to our asthma form to apply for our asthma trials.Do you have any of the following conditions?You can choose multiple options, but please select at least one.Do you have any of the following conditions?(Required) Asthma Cancer Diabetes A neurological condition such as MS or epilepsy An inflammatory condition such as Crohns or rheumatoid arthritis A heart or circulation condition such as hypertension or blood clots A viral blood condition such as HIV or Hepatitis A Issues with having blood taken Allergies, eczema, or allergic rhinitis Other NoneMedical Conditions Other(Required)Are you a smoker or have you smoked in the last 6 months?Are you a smoker or have you smoked in the last 6 months?(Required) Yes NoAre you currently pregnant, or have you been pregnant in the last 6 months?Are you currently pregnant, or have you been pregnant within the last 6 months?(Required) Yes NoHeightWhat height are you (in cm)?(Required)Don't know your height in centimetres? Use the converter tool below then type the result here.Don't know your height in centimetres? Use the converter tool below to calculate your height then enter the result in the box above.FeetInchesHeight in CMYour height in CM is:WeightWhat is your approximate weight (in kg)?(Required)Don't know your weight in kilograms? Use the converter tool below then type the result here.StonesPoundsWeight in KGYour weight in KG is:HiddenBMIDo you have a valid Passport or Driving license?Do you have a valid photo ID, UK Driving license or Passport?(Required) Yes No Not sureAre you registered with a GP in the UK?Are you registered with a GP in the UK?(Required) Yes NoSecurityTo make sure we can identify you, please provide a security question.Security Question(Required)Please select one questionChoose oneWhat was the name of your first pet?In which city or town were you born?What is the make and model of your first car?What is the name of the street you grew up on?Security Answer(Required)
