a minor child under the age of seventeen (SC,GA,VA) or eighteen (NC) [hereinafter
"my child"] who is required to have my written consent to donate
blood. I have read and understand the "Important Donor Information"
pamphlet found on The Blood Connection web site. I have read and understand
the requirements to be a blood donor. I understand that my child will be
donating voluntarily and transferring possession of a portion of his or
her blood to The Blood Connection. I understand that my child may withdraw
from the donation process at any time. I understand that in order to donate
the first time he or she will be expected to present an ID or document
with birth date. A document with my child's photograph is preferred.
A driver's permit/license, photocopy of birth certificate, passport,
school ID (listing birth date) are examples of such documents. At high
school blood drives, printouts of student rosters provided by the school
are also acceptable sources of age verification.
I agree to inform The Blood Connection if my child does not meet any of
the requirements to be a blood donor or if I believe he or she has been
infected at any time prior to donation with HIV (AIDS) or any other disease
capable of being spread to another person by blood or plasma. I understand
that a person's medical history and past lifestyle behaviors determine
suitability to be a blood donor, and that if my child is determined to
be ineligible to donate, then his or her blood donation record will include
this information.
Blood Testing: My child and I have been informed and understand that the
donated blood will be tested for laboratory evidence of infectious agents
capable of being spread through blood transfusion, including but not limited
to: Syphilis, HIV (AIDS), HIV-2, Hepatitis B & C, West Nile Virus,
HTLV (a retrovirus), and T. cruzi (a parasitic infection.) I understand
that if an insufficient amount of blood is drawn, it cannot be used for
transfusion, and some, if not all the tests as they come available and
are thought to improve the safety of the nation's blood supply. The
tests are very sensitive and detect most infections, but it is possible
that donors who are not infected will have falsely positive tests. For
some tests, TBC is required to notify and defer donors even when subsequent
test results indicate that the donor is not infected. I understand that
my child's health information will remain confidential in accordance
with State and Federal privacy and disclosure laws, and that The Blood
Connection will not routinely report results of its testing unless the
result makes my child ineligible for further donations or indicate a possible
health problem. In order to interpret and better understand these tests
The Blood Connection may contact me or my child to request a repeat blood
sample. I also understand that if testing indicates my child is no longer
eligible to donate, then his or her record will include this information.
I understand that my child's blood donation may be discarded because
of test results, and that certain test results must be reported to state
and/or local health departments as required by applicable laws and regulations.
Risks of Blood Donation: Potential common side effects of both whole blood
and automated blood collection include fainting or loss of consciousness
and injury from related falls, dizziness, nausea vomiting, bruising or
redness in the area of the venipuncture and iron deficiency. Less common,
but more serious reactions may include seizures and, rarely, nerve or blood
vessel injury in the area of the venipuncture. Rare, serious complications
include shock; blood clotting; severe allergic reactions in people sensitive
to latex or rubber, hemolysis (red cell destruction), compartment syndrome
(compression of the nerves, blood vessels and muscle inside a closed space),
and symptoms of severe low blood calcium. Blood donation removes iron and
may cause or aggravate iron-deficiency anemia.I have been
provided literature that explains the blood donation process, and that
information is also available on the Blood Connection's website at
www.thebloodconnection.org. The donation process has been explained to
me and all my questions answered to my satisfaction. I have read and understand
the above, and hereby permit The Blood Connection to draw blood, plasma,
and/or platelets from my child to be tested as required, stored, and used
as deemed advisable including providing blood locally, regionally, or nationally
to meet patient and biologics manufacturing needs.