Electronic Parent/Guardian Permission Form

Please encourage your student to take part in the selfless and life-saving act of donating blood. By allowing your child to become a blood donor, you are encouraging him or her to demonstrate great civic responsibility, maturity and a sense of community pride.

Click the link below to learn tips to help your student with a successful donation experience.

Young donor tips

BLOOD DONORS MUST:
✓ Be at least 16 years old. (Signed parental permission required for all 16-year-olds and by some sponsor groups for donors who are 17 and older.)
✓ Weigh at least 125 lbs. if 16 or 17 years old; 110 lbs. if 18 or older.
✓ Eat a good meal AND drink plenty of fluids before & after donating.
✓ Get a good night’s sleep before donating.
✓ Present a Photo ID.

Please ensure that you have read and understand the above information about blood donor criteria.*

I agree that I have read and understand the following information about blood donors.

BLOOD DONATION INCLUDES:
Registration – A series of questions are asked including your name, address, phone number, etc.

Mini-Physical – A series of questions are asked regarding your health history. You will be asked to review donor educational materials. Your temperature, blood pressure, pulse and hemoglobin level (a fingerstick test to make sure you have enough red blood cells to donate) will be checked.

Blood Donation – You will be asked to recline in a donor chair. A phlebotomist will prepare your arm by cleansing it. A sterile, disposable single-use-only needle will be used to collect the blood.

• A whole blood donation is performed by using a sterile, disposable single-use-only needle that is attached to a blood bag. Whole blood donation usually only takes about 20 minutes to donate one unit (about a pint).
• Automated donations are performed by using special machines that allow blood to be collected and separated into components. The desired component is collected and the remaining components are returned to the donor along with a saline solution to replace fluids. This process is performed using a disposable, single-use-only needle that is attached to a disposable, sterile-use-only kit that is inserted into the machine. No blood ever touches the machine. You will be asked to sign a separate consent form for this type of donation.

After Donation – You are encouraged to relax in our refreshment area and enjoy some juice and snacks to replenish your body before resuming activities.

Preventing Reactions – During and after donating, most donors have a pleasant experience. Occasionally, a donor may experience dizziness, weakness, or even faint. Often, this can be prevented by eating and drinking well before donating. The most common risk associated with blood donation is tenderness or slight bruising at the site where the needle was inserted. Our employees are trained to handle donor reactions. That care is given under the direction of a physician.

Donor Testing – Blood will be tested for certain characteristics, including tests for Hepatitis B, Hepatitis C, HIV and Syphilis. Donors will be notified of confirmed positive test results by letter or telephone call. By state law, certain positive infectious disease test results must be reported to local health departments, the Oklahoma State Health Department, the Texas State Health Department or the Arkansas State Health Department.

Please ensure that you have read and understand the information above about what a blood donation includes.*

I agree that I have read and understand the following information about what a blood donation includes.

Blood Donor Educational Materials

Blood Donor Education Materials - English

Blood Donor Educational Materials - Spanish

Please ensure that you have accessed and reviewed the Blood Donor Educational Materials above.*

I agree that I have read and understand the information provided on the Blood Donor Educational Materials provided above.

Parent/Guardian: To discuss a concern after your student’s donation or if you believe your student’s blood may be harmful if given to a patient, please call 1-800-375-7654.

Donor Name*

Nick Name

Donor Age*

Donor Date of Birth*

Donor Gender*

Donor Phone Number

Donor Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Intended Date of Donation / Date of Blood Drive*

Date

Will donation be given at a school sponsored blood drive?*

YesNo

Select STATE for school sponsored blood drive*

Select school sponsored blood drive in Arkansas (If school is not listed, select *NOT LISTED) *

Select school sponsored blood drive in Oklahoma (If school is not listed, select *NOT LISTED)*

Select school sponsored blood drive in Texas (If school is not listed, select *NOT LISTED)*

Name of school sponsored blood drive*

Is your student interested in enrolling into our Honor Cord Program?*

YesNo

Parent/Legal Guardian Name*

Primary Phone Number*

Secondary Phone Number

Parent/Legal Guardian Email

example@example.com

THE FOLLOWING CONSENT MUST BE COMPLETED

I, the parent or legal guardian of the individual listed below, hereby authorize and approve my child to give a voluntary blood donation, either whole blood or automated. By providing my consent, I acknowledge that I have read the information provided and give permission for my child to undergo all tests and procedures required for the blood donation process, including any additional testing as directed by a blood center physician as well as medical care should he or she experience a donor reaction. I understand the procedure of collecting blood is recognized as safe, but blood donation is not without risk. Risks include, but are not limited to, lightheadedness, nausea, fainting, passing out, falling with injury/soreness, bruising, and nerve injury at or near the phlebotomy site. Long-term injuries and fatalities are rare but have been reported. Sometimes a blood donation phlebotomy procedure may bring about a need for additional medical treatment. Once your consent to donate is submitted for the individual listed below, the parent/legal guardian authorization is good for one donation in the next 30 days.

Please ensure that you have read and understand the consent information above.*

I authorize my child to make a voluntary blood donation with Our Blood Institute, either whole blood or automated.I acknowledge that all information I provided in this form is true and accurate.I acknowledge that this authorization is good for one donation given within 30 days of consent date provided.

Parent/Guardian Signature*

Date Signed*

Consent Expiration Date*

Date

Electronic Parent/Guardian Permission Form

Donor Information

Parent/Legal Guardian Contact Details

Parent/Legal Guardian Acknowledgment Authorization

OBI-DS-FORM-0122 / Rev: 01/ 21 Apr 2025