Form Ii-2.001d - Blood Donation - 16 Year Old Permission printable pdf download

Form Ii-2.001d - Blood Donation - 16 Year Old Permission

Rhode Island Blood Center

Donor Services Department

405 Promenade St.

Providence, RI 02908

THIS CONSENT MUST BE COMPLETED AND PRESENTED ON THE DAY OF THE BLOOD

DONATION.

16 Year Old Permission Form

PLEASE PRINT THE FOLLOWING INFORMATION IN BLACK OR BLUE PEN

Donor Information

Donor Name: ____________________________________________ Age: _______ Birth date: __________

High School (if applicable): _________________________________________________________________

By signing this consent, I understand that abnormal results of laboratory testing will be provided to my parent

or guardian (if age sixteen), and all appropriate State of Rhode Island agencies required by law (regardless of

age). Investigational testing may also be performed, which, if reactive, may necessitate donors return for further

testing.

Student Signature: ______________________________________________________ Date: ___________

Parent/Guardian Information

Parent/Guardian Name: ____________________________________________________________________

Street Address: ___________________________________________________________________________

Donor City/State: _________________________________________________________________________

Zip Code: _________________

Daytime/Cell Phone: __________________________________________

By signing this document, I acknowledge I am the parent or guardian of the individual listed above. I also

acknowledge that I have read and understand the information on the attached “General Information about Blood

Donation” forms, acknowledge that additional information is available by phone using the contact numbers

provided, and hereby consent for my child to make a voluntary blood donation through the Rhode Island Blood

Center. This consent includes submission to all tests, examinations, and procedures customary in the connection

with the blood donation process, including the donor consent statement. Investigational testing may also be

performed, which, if reactive, may necessitate donors return for further testing. I also declare that my child

weighs at least 130 pounds as required for this donation.

Also, I give my child consent to donate Automated Double Red Cell Collection if my child meets eligibility

criteria.

yes

Parent/Guardian Signature: ________________________________________________ Date: __________

Revision 2 implemented on __________

Form II-2.001d

Confidential and Proprietary

10/05/15

White Form – RIBC copy

Pink Form – School copy

Page 1 of 1

Form Ii-2.001d - Blood Donation - 16 Year Old Permission