Fillable Printable Blood Donor Parent/Guardian Consent Form - Kansas

Blood Donor Parent/Guardian Consent Form - Kansas

Blood Donor Parent/Guardian Consent Form

Your child has expressed an interest in donating blood. Because one blood donation can be separated into two components, your

child has the potential to save two lives with a single donation. We hope that you support and encourage your child’s decision to

donate blood. He or she is showing civic responsibility, maturity and a sense of community pride by donating blood.

Blood donation is a safe procedure using single use sterile supplies, but reactions such as lightheadedness, fainting, bruising or

nerve injury occasionally occur. Further, the likelihood of a moderate to severe reaction is less than 2% for this age group. The

average iron loss is 250 mg. per whole blood donation. Drinking plenty of fluids and eating well can reduce donor reactions. We

encourage the use of applied muscle tension exercises during donation.

State law requires written consent by parent or guardian for 16-year olds to donate blood. In addition, if donating at a high school

blood drive, some schools require similar consent even for older students.*

A photo ID and proof of age are required for high school donors.

If you consent to your child’s donating, please complete the consent form at the bottom of this page.

All blood donations are screened for several blood borne diseases. You will be notified if your 16-year old child’s donation tests

positive for these diseases. In that case, your child may be contacted for follow-up testing. Donors with positive test results are

placed on a deferral list and the blood is not used for treatment or care purposes. Positive test results and the donor’s name are

reported to health agencies as required by law. In some instances, such as when an insufficient amount of blood is collected,

testing for infectious diseases may not be possible.

If you have any questions regarding your child’s decision, please call 816-968-4061 or 1-800-245-7035.

* Persons 17 years of age or older may donate without consent of parents or guardians (unless required by your high school’s

principal.)

Please fill out bottom half of form and return only the bottom portion. Keep the top for your records.

DRD.04.F018 Version 6.0

Community Blood Center Administrative Offices: 4040 Main Street Kansas City, MO 64111

Please use ink to complete this form

I give permission/consent for _______________________________________, my son/daughter or ward, to make a voluntary

donation of blood to Community Blood Center.

Community Blood Center will notify both my 16-year old child and me if my child receives positive test result(s) for certain blood

borne diseases and my child may be contacted for follow-up testing. If tests are confirmed positive for HIV, hepatitis or syphilis

(or other diseases as may be required by law or regulation), my child’s name will be reported to the Department of Health.

A signed consent of parent/guardian is required for each donation until the donor reaches the age of 17.

Parent/Guardian Name (print) __________________________________________________ Date __________________

Address_________________________________________________________________

City/State/Zip ____________________________________________________________

Phone Number (_____)_____________________________________________________

Signature of Parent/Guardian ______________________________________________

I confirm that the consent given based on the above signature is that of my parent/legal guardian. I have read all information in

this form and agree to parental/guardian test notification.

Signature of Donor ______________________________________________________ Date____________________

DRD.04.F018 Version 6.0 Effective Date: 02/06/13