Be The Cure Registry

(by Jeevan Stem Cell Foundation)

Registered Public Charitable Trust since 1995
Email:stemcell@jeevan.org
Website: www.jeevan.org

DONOR REGISTRATION AND CONSENT FORM

PLEASE FILL THE FORM IN CAPITAL LETTERS AFTER UNDERSTANDING THE DONATION PROCESS. YOUR COMMITMENT IS ESSENTIAL


















Additional Contact Details




HAVE YOU DONATED BLOOD/PLATELETS IN THE PAST?

YesNo
If yes, how many times:

Informed Consent

•I hereby consent to the taking of a blood sample / buccal swabs / saliva in order to carry out HLA typing. I transfer the ownership of the blood sample / buccal swabs / saliva to Jeevan Stem Cell Foundation.
•I have been informed by Jeevan Stem Cell Foundation that after HLA typing of my blood sample / buccal swabs / saliva it will be included into the database.
I understand that the HLA data will be used by Jeevan Stem Cell Foundation or its assignees in future to find a matching donor for patients, for analysis and publications to find ways to improve easy access to matching stem cells for patients with blood cancers, thalassemia and other blood disorders.

I have given my consent to:

  1. Be a voluntary peripheral blood stem cell donor after understanding the process.
  2. Release necessary personal and genetic information (no names) to affiliated national and international bone marrow donors registries for the purpose of matching with potential bone marrow transplant recipients.
  3. Make myself available for confirmatory typing / additional tests / GCSF injections and stem cell donation, if I am a match.
  4. Keep Jeevan Stem Cell Foundation updated about any change in my contact details. (stemcell@jeevan.org)
  5. Be contacted by Jeevan Stem Cell Foundation through the mobile and / or email.
  6. I will stay committed to donate If and when I am found to be a match.
Date (*):
Place (*):