Child Participant Registration:
Full Name Child
*
First Name
Last Name
Parent / Guardian / Carer Name
Date of Birth Child
-
Day
-
Month
Year
Date
Gender Child
Parent or Guardian Phone Number
*
-
Area Code
Phone Number
Parent or Guardian Mobile Number
Where you live
Town
City
E-mail
Medical Conditions
Allergy - nut allergy
Allergy - peanut allergy
Ankylosing Spondylitis
Asthma
Cancer
COPD
Cluster Headaches
Crohns disease
Diabetes type 1
Diabetes type 2
Macular Degeneration
Fibromyalgia
Glaucoma
High Blood Pressure
Low Blood Pressure
Lupus
Migraine
Multiple Sclerosis
Osteoarthritis
Rheumatoid Arthritis
None of the above
Any other condition please specify in in the box below
Please list the medication you are on below:
M1
M2
M3
M4
M5
Do you currently self-inject medication to treat your health?
Yes using a pen device
Yes using a pre filled syringe
Yes with syringe and vile
No I do not self inject
Are you left or right handed
Left
Right
Do you wear glasses or contact lenses to correct your vision?
Yes
No
Are any of your close friends or family employed by any of the following:
Pharmaceutical manufacturer
Medical equipment manufacturer
Market research or advertising company
Medical office, clinic or hospital
None of the above
Submit
Should be Empty: