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    NSTP

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    Arjeh Carl
    This document is a blood donation endorsement and waiver form for students in the National Service Training Program (NSTP) at Saint Louis University (SLU). It requests that a specified student be allowed to donate blood at a partner institution. It collects information about the donation and has waivers signed by the student and guardian allowing the institution to use the donated blood and waiving liability for any issues from the donation. The purpose is to replace blood used by patients through the SLU NSTP's blood donation project.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    NSTP

    Uploaded by

    Arjeh Carl
    78 views3 pages
    This document is a blood donation endorsement and waiver form for students in the National Service Training Program (NSTP) at Saint Louis University (SLU). It requests that a specified student be allowed to donate blood at a partner institution. It collects information about the donation and has waivers signed by the student and guardian allowing the institution to use the donated blood and waiving liability for any issues from the donation. The purpose is to replace blood used by patients through the SLU NSTP's blood donation project.

    Original Description:

    BLOOD DONATION ENDORSEMENT AND WAIVER FOR SLU NSTP STUDENTS

    Copyright

    © © All Rights Reserved

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    This document is a blood donation endorsement and waiver form for students in the National Service Training Program (NSTP) at Saint Louis University (SLU). It requests that a specified student be allowed to donate blood at a partner institution. It collects information about the donation and has waivers signed by the student and guardian allowing the institution to use the donated blood and waiving liability for any issues from the donation. The purpose is to replace blood used by patients through the SLU NSTP's blood donation project.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    78 views3 pages

    NSTP

    Uploaded by

    Arjeh Carl
    This document is a blood donation endorsement and waiver form for students in the National Service Training Program (NSTP) at Saint Louis University (SLU). It requests that a specified student be allowed to donate blood at a partner institution. It collects information about the donation and has waivers signed by the student and guardian allowing the institution to use the donated blood and waiving liability for any issues from the donation. The purpose is to replace blood used by patients through the SLU NSTP's blood donation project.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    SLU NSTP

    Form 43 SAINT LOUIS UNIVERSITY


    AUGUST, 2019 COMMUNITY EXTENSION AND OUTREACH PROGRAMS OFFICE
    NATIONAL SERVICE TRAINING PROGRAM (NSTP) OFFICE
    Student Center First Basement, Assumption Rd., 2600 Baguio City
    Cp no.09460843457 E-address [email protected]

    CICM • SLU • NSTP • CICM •SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU• NSTP • CICM • SLU

    BLOOD DONATION ENDORSEMENT AND WAIVER FOR SLU NSTP STUDENTS


    (Accomplish in three copies: copy for administering institution, copy for student, and copy for Project Facilitators )

    DATE: _____________
    Institution: ________________________________

    Please accommodate __________________________________currently enrolled in our ____________


    (NSTP 1/ NSTP 2 class) with class code _______________, for blood donation in your institution. Please record
    this blood donation under the SLU NSTP’s blood donation project with your institution this current term. This
    blood donation, if successful, will replace the blood used by patient ________________________________
    from your blood bank.
    May we further request that the information below be accomplished and be provided our office. Please
    send this accomplished information back to us through the donor/bearer:

    Status of donation/bleeding (pls. check): ___successful ___unsuccessful ___deferred/Reason:__________


    Blood type: __________ Blood volume donated: ___________Date of donation:_____________

    ______________________________________
    Name and Signature of attending lab personnel

    Thank you very much.

    Respectfully yours, Endorsed by:

    SALLY P. TABEC, LPT,MA FIL CHARMAINE P. MENDOZA, LPT, MAED


    Project Supervising Instructor /NSTP Coordinator Director, CEOPO

    WAIVER/BLOOD DONOR‘S VOLUNTARY AND FREE CONSENT


    I, ________________________________, am voluntarily donating without remuneration my blood to medical
    patients in need and/or as referred through the institution above under the SLU NSTP Blood Services Project. I
    understand that my blood will be screened to ensure its quality and safety. I authorize the institution to dispose
    my donated blood to needy medical patients.
    Meanwhile, I shall not hold the University and the hospital or their representatives liable for any untoward
    incident that may occur to me as a consequence of my blood donation.

    __________________________________ ______________________________________________
    Name and Signature of Donor Name and Signature of Parent/Guardian
    Date: ______________________ Date:________________________

    Note: Please do not hesitate to ask question, if necessary.

    By my signature herein, I hereby give my consent to SLU’s collection, processing & storage of the above information pursuant to the
    provisions of Republic Act No. 10173 or the Data Privacy Act of 2012
    CICM• SLU • NSTP • CICM •SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM

    CREATING INITIATIVES FOR COMPASSION AND MERCY


    SLU NSTP
    Form 43 SAINT LOUIS UNIVERSITY
    AUGUST, 2019 COMMUNITY EXTENSION AND OUTREACH PROGRAMS OFFICE
    NATIONAL SERVICE TRAINING PROGRAM (NSTP) OFFICE
    Student Center First Basement, Assumption Rd., 2600 Baguio City
    Cp no.09460843457 E-address [email protected]

    CICM • SLU • NSTP • CICM •SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU• NSTP • CICM • SLU

    BLOOD DONATION ENDORSEMENT AND WAIVER FOR SLU NSTP STUDENTS


    (Accomplish in three copies: copy for administering institution, copy for student, and copy for Project Facilitators )

    DATE: _____________
    Institution: Philippine Red Cross -___________________

    Please accommodate __________________________________currently enrolled in our ____________


    (NSTP 1/ NSTP 2 class) with class code _______________, for blood donation in your institution. Please record
    this blood donation under the SLU NSTP’s blood donation project with your institution this current term. This
    blood donation, if successful, will replace the blood used by patient ________________________ from your
    blood bank.
    May we further request that the information below be accomplished and be provided our office. Please
    send this accomplished information back to us through the donor/bearer:

    Status of donation/bleeding (pls. check): ___successful ___unsuccessful ___deferred/Reason:__________


    Blood type: __________ Blood volume donated: ___________Date of donation:_____________

    ______________________________________
    Name and Signature of attending lab personnel

    Thank you very much.

    Respectfully yours, Endorsed by:

    SALLY P. TABEC, LPT,MA FIL CHARMAINE P. MENDOZA, LPT, MAED


    Project Supervising Instructor /NSTP Coordinator Director, CEOPO

    WAIVER/BLOOD DONOR‘S VOLUNTARY AND FREE CONSENT


    I, ________________________________, am voluntarily donating without remuneration my blood to medical
    patients in need and/or as referred through the institution above under the SLU NSTP Blood Services Project. I
    understand that my blood will be screened to ensure its quality and safety. I authorize the institution to dispose
    my donated blood to needy medical patients.
    Meanwhile, I shall not hold the University and the hospital or their representatives liable for any untoward
    incident that may occur to me as a consequence of my blood donation.

    __________________________________ ______________________________________________
    Name and Signature of Donor Name and Signature of Parent/Guardian
    Date:______________________ Date:________________________

    Note: Please do not hesitate to ask question, if necessary.

    By my signature herein, I hereby give my consent to SLU’s collection, processing & storage of the above information pursuant to the
    provisions of Republic Act No. 10173 or the Data Privacy Act of 2012
    CICM• SLU • NSTP • CICM •SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM

    CREATING INITIATIVES FOR COMPASSION AND MERCY


    SLU NSTP
    Form 43 SAINT LOUIS UNIVERSITY
    AUGUST, 2019 COMMUNITY EXTENSION AND OUTREACH PROGRAMS OFFICE
    NATIONAL SERVICE TRAINING PROGRAM (NSTP) OFFICE
    Student Center First Basement, Assumption Rd., 2600 Baguio City
    Cp no.09460843457 E-address [email protected]

    CICM • SLU • NSTP • CICM •SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU• NSTP • CICM • SLU

    BLOOD DONATION ENDORSEMENT AND WAIVER FOR SLU NSTP STUDENTS


    (Accomplish in three copies: copy for administering institution, copy for student, and copy for Project Facilitators )

    DATE: _____________
    Institution: Saint Louis University___

    Please accommodate __________________________________currently enrolled in our ____________


    (NSTP 1/ NSTP 2 class) with class code _______________, for blood donation in your institution. Please record
    this blood donation under the SLU NSTP’s blood donation project with your institution this current term. This
    blood donation, if successful, will replace the blood used by patient ________________________ from your
    blood bank.
    May we further request that the information below be accomplished and be provided our office. Please
    send this accomplished information back to us through the donor/bearer:

    Status of donation/bleeding (pls. check): ___successful ___unsuccessful ___deferred/Reason:__________


    Blood type: __________ Blood volume donated: ___________Date of donation:_____________

    ___________________________________
    Name and Signature of attending lab personnel

    Thank you very much.

    Respectfully yours, Endorsed by:

    SALLY P. TABEC, LPT,MA FIL CHARMAINE P. MENDOZA, LPT, MAED


    Project Supervising Instructor /NSTP Coordinator Director, CEOPO

    WAIVER/BLOOD DONOR‘S VOLUNTARY AND FREE CONSENT


    I, ________________________________, am voluntarily donating without remuneration my blood to medical
    patients in need and/or as referred through the institution above under the SLU NSTP Blood Services Project. I
    understand that my blood will be screened to ensure its quality and safety. I authorize the institution to dispose
    my donated blood to needy medical patients.
    Meanwhile, I shall not hold the University and the hospital or their representatives liable for any untoward
    incident that may occur to me as a consequence of my blood donation.

    __________________________________ ______________________________________________
    Name and Signature of Donor Name and Signature of Parent/Guardian
    Date:______________________ Date:________________________

    Note: Please do not hesitate to ask question, if necessary.

    By my signature herein, I hereby give my consent to SLU’s collection, processing & storage of the above information pursuant to the
    provisions of Republic Act No. 10173 or the Data Privacy Act of 2012
    CICM• SLU • NSTP • CICM •SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM • SLU • NSTP • CICM

    CREATING INITIATIVES FOR COMPASSION AND MERCY

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