1st “Dugo sang Masa… Halad sang mga Ilonggo kag Kooperatiba”

An Iloilo Provincial Cooperatives Annual Bloodletting Activity

BLOOD DONOR COMMITMENT & CONSENT FORM

Cellphone No.

FB Name

FAMILY NAME FIRST NAME MIDDLE NAME SUFFIX

Birthdate: Birthplace:
Gender:  Male  Female
Month Date Year

Civil Status: Name of Spouse: Cellphone No.

Nationality:
Email:
Religion: No. of Dependents:

Residence Address: Telephone No.

Provincial Address Telephone No.

Name of Cooperative: Telephone No.

Office Address:

MY LIFE-SAVING COMMITMENT AND CONSENT TO DONATE BLOOD

I HEREBY WILLINGLY COMMIT AND CONSENT TO DONATE BLOOD by attending on the appointed date of the
blood-letting activity. I submit to the proper procedures necessary to the screening and blood-letting procedures by
providing my blood and following appropriate protocols before, during and after donating blood.

If I am qualified, my blood will be given to ANY patient in need. I am also granting permission to be listed in the
Philippine Red Cross registry until I will no longer donate.

When called for a patient in need, I shall respond quickly with my utmost best effort.

This decision is known to my family and friends so I have their support if I am called to donate. All information given
in this form are true and correct to my knowledge.

I also allow the Iloilo Provincial Cooperative Development Council and the Philippine Red Cross-Iloilo Chapter to use
the data herein for legitimate purposes.

My signature indicates my commitment, consent and full participation after having read and understood satisfactorily
this Commitment and Consent Form as a blood donor.

____________________________________
 (Signature over printed name)

Date Signed: _____________________________