Minor Donor Permit United Blood Services (Page 2 of 2) in pdf

blood center evaluates eligibility for younger donors

of breath, chest pain, and decreased blood pres-

based on weight and height to determine blood vol-

sure.

ume. The chart on page 1 indicates whether your

In addition, during automated blood collections

blood volume is sufficient for you to donate. Please

some common side effects that are easily resolved

review it carefully. Other possible complications

are due to the anticoagulant and include numbness

include fatigue, decreased exercise tolerance for 3-

and tingling sensations, muscle cramping, and chil-

5 days and, very rarely, allergic reaction, shortness

liness. Less common complications include hemol-

ysis and air embolism.

If you have any questions, please contact the blood center.

STUDENTS: Take these steps on the day of donation for a good blood donation experience.



If you are 16, bring this signed Minor Donor Permit when you donate. The signature block is below.

(Some states and schools may require signed parental consent for 17-year-old donors as well.)



BRING ID containing name and one of the following: birth date, blood center donor number, or photo.



You must pass the physical and health history examination given prior to donation. If you have any ques-

tions regarding your eligibility, please check with your Blood Drive Coordinator or the blood center.



Eat a healthy meal before donating, even if you do not normally eat three meals a day.



Drink 16 ounces of fluid 10-30 minutes before donating (soda, coffee, and tea don’t count!).

PARENTS/GUARDIANS: Help your student have a good blood donation experience.

The Day Before Donation: Make sure your student eats a salty snack, like chips or pretzels, and has a meal

that is higher in sodium, such as fast food, canned soup, pizza, etc. Physicians recommend this because do-

nors lose about a gram of sodium during donation. Replacing some of that sodium ahead of time makes do-

nors thirsty. Being well-hydrated helps donors maintain blood volume and can prevent dizziness or fainting.

The Day of Donation: Make sure your student has a light meal before donating, and encourage your student

to carefully follow our directions.

Our staff are specially trained to respond to donor reactions. We will:



Give your student reading material and instructions on how to have a safe, comfortable blood donation.



Teach your student muscle tensing exercises to use during and after donation.



Provide a sports drink or another beverage and a salty snack.



Tell your student to spend at least 15 minutes in our refreshment area.

Please be sure that you and your student have read the information provided. If required by your state

or school, your student must bring this signed Minor Donor Permit form in order to donate. Infor-

mation is also available online at

A sample from each blood donation will be tested for HIV (AIDS), HTLV hepatitis, syphilis, and other infectious

agents as required by regulations. These tests are performed to protect the patients who receive blood. Posi-

tive test results will be disclosed as authorized by law, and the donor will be notified. In some cases, blood

center staff may need to discuss test results with the donor. Per California law, it is the donor’s decision

whether his/her parents are to be included in that discussion.

I give my permission for my student to donate and for that donation to be tested as explained above.

Minor Donor’s Name (Please Print)

Signature of Parent/Guardian

Date

On the day my student donates, I can be reached at this phone

number:

Parent/Guardian’s Name (Please Print)

BS 319 (Rev. 9)

MAN100

Minor Donor Permit United Blood Services Page 2

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