Registration Form: Blood/ Plasma Donor
Please fill the following details for further registration. Details will be kept confidential. You are our Savior, We are proud of your initiative.
Email *
Name of the Donor *
Age of the Donor *
You are from.. *
Gender *
Phone Number *
Your Contact Details/ Residential address *
Did you ever test Covid positive? *
Date of Tested positive
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DD
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YYYY
Date of Recovery from Covid 19
MM
/
DD
/
YYYY
Are you donating plasma/ Blood first time? *
If donated before, please mention the date
MM
/
DD
/
YYYY
Your Blood Group is: *
Do you suffer from any of the following disease or witnessing any of its symptoms/ or any other medical treatment going on? *
Do you consume any substance/ alcohol or any other? *
Do you have Aadhar card *
Do you have Covid Negative report? *
Note:-I am volunteering as a Blood/ Plasma Donor. I have read the eligibility criteria and confirm that I am eligible to donate Plasma/ Blood. I authorize Lucknow University, LU to share my name, mobile number, email address & postal address to the individual / organizations who is in need of Blood / Plasma. I release Lucknow university, all organized trusted volunteers and assistants in this program from all the damages that occur. I agree to hold harmless Lucknow University for its use of the information for the exclusive purpose mentioned above. I hereby confirm that I have read all the information stated above and based on that I am ready to be a donor. *
We are grateful that you are coming forward for saving lives, would you also like to become our volunteer in this campaign for awareness generation and motivating others to donate Blood/ Plasma? *
A copy of your responses will be emailed to the address you provided.
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