San Isidro Senior High School

AFP/PNP Housing, San Isidro, Rodriguez, Rizal

MOBILE BLOOD DRIVE

In coordination with National Children’s Hospital and Supreme Student Government of San Isidro Senior High School

BLOOD DONOR'S CONSENT FOR AGES 16 AND 17

Date: ____________

“I am voluntarily giving my blood through the National Children’s Hospital, without remuneration, for the use of persons
in need of this vital fluid without regard to rank, color, creed, religion or political persuasion. I understand that all the
questions are pertinent for my safety and for the benefits of the patient who will undergo blood transfusion. I understand
that my blood will be screened for Malaria, Syphilis, Hepatitis B, Hepatitis C and HIV.

I authorize the Red Cross to dispose of my donated blood in anyway it may deem advisable for the benefit of
suffering humanity. I certify that I, to the best of my knowledge, will truthfully answer all the questions in the Donor
Interview Sheet.”

“I, as parent/guardian allow my son/ daughter, ________________________________________ to donate blood.

_____________________________ _______________________________
Name and Signature of Donor Name and Signature of Parent/Guardian

BO-004
__________________________________________________________________________________________________

San Isidro Senior High School

AFP/PNP Housing, San Isidro, Rodriguez, Rizal

MOBILE BLOOD DRIVE

In coordination with National Children’s Hospital and Supreme Student Government of San Isidro Senior High School

BLOOD DONOR'S CONSENT FOR AGES 16 AND 17

Date: ____________

“I am voluntarily giving my blood through the National Children’s Hospital, without remuneration, for the use of persons
in need of this vital fluid without regard to rank, color, creed, religion or political persuasion. I understand that all the
questions are pertinent for my safety and for the benefits of the patient who will undergo blood transfusion. I understand
that my blood will be screened for Malaria, Syphilis, Hepatitis B, Hepatitis C and HIV.

I authorize the Red Cross to dispose of my donated blood in anyway it may deem advisable for the benefit of
suffering humanity. I certify that I, to the best of my knowledge, will truthfully answer all the questions in the Donor
Interview Sheet.”

“I, as parent/guardian allow my son/ daughter, ________________________________________ to donate blood.

_____________________________ _______________________________
Name and Signature of Donor Name and Signature of Parent/Guardian

BO-004