Stone Bridge High School
Blood Donation Permission Form
This form must be submitted PRIOR to the Blood Drive.
Student’s Full Name:
Full Name of Parents/Guardians:
Home Address of Student: (include number, street, city)
Home Phone Number (with area code):
EMERGENCY phone numbers: 1.
2.
Describe any medical conditions or special needs of the above named student:
Student Contact Information:
Email address:
1st Block teacher: ________________________________
ROOM #: _______________________
5th Block teacher: ________________________________
ROOM#: ________________________
Parental Agreements:
I believe, to the best of my knowledge, that my child meets the requirements below for donating blood:
Please initial be each requirement.
_____Age:
_____Health:
_____Weight:
_____Identification:
16 years minimum (must sign the consent form attached)
Generally good health-has been well for 3 consecutive days (no symptoms of illness
including colds)
110 pounds minimum
Must provide a photo ID (such as driver’s license) at time of donation.
I give my permission for my child to donate blood on November 16, 2015 to the INOVA Blood Donor Services.
_____________________________________________ _______________________
Signature of Parent/Guardian
Date
SIGNATURE INDICATES AGREEMENT WITH ALL CONDITIONS LISTED ABOVE
Attached is a more extensive listing of donor eligibility and requirements.
Any questions, please call Sarah Shangraw @ SBHS, 571.252.2200.
This blood drive is sponsored by Stone Bridge Interact, ICC, and Senior Class Officers in conjunction
with INOVA Blood Donor Services.