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Stem Cell Donation Volunteer Application Form
Personal Information
Name *
Date of Birth * (MM/DD/YYYY)
Email Address *
Phone Number *
Address *
Eligibility Criteria
Have you previously registered as a stem cell donor? *
Yes
No
Are you between 18 and 60 years old? *
Yes
No
Do you weigh at least 50kg (or) 110 pounds? *
Yes
No
Are you in good health? *
Yes
No
Medical History
Have you ever been diagnosed with any of the following? *
Cancer
Autoimmune disorders
Blood disorders
Infectious diseases (e.g., HIV, Hepatitis)
Other (please specify)
Please disclose any medical conditions or medications:
Availability
Are you available for a 4-6 hour donation process? *
Yes
No
Declaration
I declare that the information provided is accurate and true. I understand that providing false information may lead to rejection of my application.
I agree to the terms and conditions
I understand the PBSC donation process and risks involved.
Submit Application
