Jeevan Stem Cell Foundation - Be the Cure

+91 44 4350 4246 bethecure@jeevan.org

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About Us
Join the Registry
Support
FAQS
Contact Us

Jeevan Stem Cell Foundation

(By Jeevan Stem Cell Foundation)
22, Wheatcrofts Road (Second Floor), Nungambakkam, Chennai 600 034
Mobile: +91 89399 99216/+91 97908 97918 • Email: bethecure@jeevan.org • Website: bethecure.in

DONOR REGISTRATION AND CONSENT FORM

PERSONAL DETAILS

Name

Ref. by

Family Name/Initial

Date of Birth (dd/mm/yyyy)

Blood Group

Gender

Authorized Govt ID

ID Number

CONTACT DETAILS OF DONOR

25% Complete

Landline Number

Mobile Number

Email ID

Native state

Mother Tongue

Current Address

State

City

Pincode

Use current address as permanent address (Check this box if your permanent address is same as current address.)

Permanent Address

State

City

Pincode

CONTACT DETAILS OF CLOSE RELATIVE / FRIEND

(In case we're unable to reach you)

50% Complete

Select Contact
Relative Friend

Name of Close Relative / Friend

Address of Close Relative / Friend

State

City

Pincode

Email ID

Mobile Number

MEDICAL INFORMATION OF DONOR (Please answer the following questions correctly)

75% Complete

Have you donated Blood/Platelets in the past?

Yes No

If yes, how many times:

Have you been refused as a blood donor ?

Yes No

If yes, when:

Have you had any of the following illnesses in the past?

Bleeding Tendency

Yes No

If yes, when:

Cancer

Yes No

If yes, when:

Diabetes

Yes No

If yes, when:

Fits

Yes No

If yes, when:

Fainting attacks

Yes No

If yes, when:

Heart Disease

Yes No

If yes, when:

High BP

Yes No

If yes, when:

HIV/AIDS

Yes No

If yes, when:

Hepatitis/Jaundice

Yes No

If yes, when:

Malaria

Yes No

If yes, when:

Tuberculosis

Yes No

If yes, when:

Venereal Disease

Yes No

If yes, when:

Have you ever received blood Transfusion?

Yes No

If yes, when:

Do you take any Medicines regularly?

Yes No

If yes, when:

Informed Consent

95% Complete

I hereby consent to the taking of a blood sample / buccal swabs in order to carry out HLA typing. I transfer the ownership of the blood sample / buccal swabs to Be The Cure Registry. I have been informed by Be The Cure Registry that after HLA typing of my blood sample, it will be included into the database. I understand that the HLA data will be used for research to find ways to improve easy access to matching stem cells for patients with blood cancers and thalassemia.

I have given consent to be a voluntary peripheral blood stem cell donor.
I confirm the correctness of my personal data above and I agree that it is stored at Be The Cure Registry in order to search for donors.
I will make myself available for confirmatory tests when required.
I will keep Be The Cure Registry updated about any change in my contact details.
I agree to being contacted by Be The Cure Registry through the mobile and / or email.
I have the option to change my mind about being a voluntary donor at any time.

All above information is confidential and is for office use only.
(The Application will not be processed if the Form is not duly completed.)

contact details

Jeevan Stem Cell Foundation
22, Wheatcrofts Road (Second Floor) Nungambakkam Chennai 600034. India
+91 89399 99216/+91 97908 97918

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