Biomedical Research Centre Young Person's Advisory Group Application

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* 1. Name

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* 2. Date of birth (NOTE You must be aged between 14 and 18 to join the group)

Date / Time

Date

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* 3. email address

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* 4. Telephone number

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* 5. Parent/carer name

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* 6. Parent/carer email, telephone number or postal address (we will need this so that we can contact them for consent to work with you)

Address

Address 2

London Borough

Post Code

Email Address

Phone Number

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* 7. School name and address (we need this to ensure that you are eligible to join the group. We can only accept applications from students from schools in Lambeth, Southwark or Lewisham)

School name

Address *

Address 2

London Borough

Post Code *

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* 8. Why do you want to join the group? 150 words

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* 9. What do you think you can bring to the group? (What skills and experience do you have? Have you taken part in research? What are you doing or have done at school that could help this group?) 150 words