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PARENT CONSENT FORM

16-year-olds must bring a Parent Consent Form signed by your parent or guardian. If 17 or 18 years old and your school requires, please bring a signed Parent Consent Form.
BLOOD DONOR ID NUMBER (BloodSource Staff Use Only)

Thank you for providing your consent for your child to donate blood. The state of California allows 16-year-olds to donate blood with written parental/guardian consent. Although not required by law, some schools require consent forms from students who are 17 and 18 years old. You should be very proud of your sons or daughters decision to donate. In fact, high school students donate over 18,000 lifesaving pints of blood with BloodSource each year!
IMPORTANT INFORMATION FOR PARENTS

We will ask your son or daughter questions about his or her health, medication use, sexual behavior, travel and other risk factors for infectious diseases during a private and confidential interview. I understand that BloodSource will maintain the confidentiality of information obtained about a donor and will release a donors confidential information to the donors parent/guardian only with the donors consent. I understand that positive test results will be reported to County or State health agencies as required by law, and the donor will be notified directly. Test results will be released to the donors parent/guardian only with the donors consent. I understand that BloodSource will attempt to notify the parents of 16-year-old donors or any student who donates at a high school drive who experiences loss of consciousness or serious injury. In some cases, upon the request of a school district, a school official may also be notified. I understand donating blood lowers the bodys iron levels, sometimes causing donors to become iron deficient. Some blood donors especially young women are at higher risk for iron deficiency. For most donors, iron deficiency is not believed to cause significant health problems. Recent research, however, suggests that iron deficiency in a pregnant woman may possibly cause harm to her unborn child. Therefore, it is BloodSources policy not to collect blood from women who think they may be pregnant or who wish to become pregnant in the near future. I understand that BloodSource medical professionals are mandated by California law to report physical abuse, sexual abuse, emotional abuse and/or neglect involving anyone under the age of 18. I understand a donor may feel tenderness or have bruising at the site where the needle was inserted. Infrequently, a donor may feel weak, dizzy or experience fainting. On rare occasions, a donor may experience some bleeding, an infection or nerve injury at the site where the needle was inserted. I do hereby give my consent for (Donors Full Name)________________________________________, at his or her discretion, to donate blood to BloodSource on (Date)___________________________________________________. _________________________________________________( ______)_____________________________________ Signature of Parent or Guardian Phone Date (PLEASE SIGN IN BLUE OR BLACK INK ONLY)
Donors Age: Donors Date of Birth:

Yes, you do save lives. | www.bloodsource.org | 866.822.5663 | not-for-profit since 1948


(WHSE # 30123) NRS.REG.003 | 06/10/13 | Page 1 of 2 | (Page 2 Information Only)