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SKMT BLOOD DONORS CLUB MEMBERSHIP FORMMRD/SBDCMF/R/08

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Marketing & Resource Development DepartmentSKMT Blood Donors’ Club

Membership Form

PERSONAL DETAILS

Name:…………………………………………………………………….………Father’s Name:………………………………………………………………………………….………

College/workplace address: ………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………….………………… Tel:………………………...........................................…..

Home address:……………………………………………………………………………………………………………………………………………………………………………………

Tel: ……………………………………………………………………… Mobile:…………………………………………………………………….……

E-mail: ……………………………………………………………….

Date of Birth: …………………………………………………….. Gender: Male Female

NIC # …………………………………………………………....…….

Blood Type: (Please encircle)

A POSITIVE A NEGATIVE B POSITIVE B NEGATIVE

O POSITIVE O NEGATIVE AB POSITIVE AB NEGATIVE

If you are not aware of your blood group, please visit our Blood Bank to donate a unit of blood and get your Blood Group Card.

What is the best way to contact you? Home Telephone Mobile E-mail

What is the best time to contact you?Weekdays (Mon-Sat) From…………..To…………….Weekend / Holidays From…………..To…………….

Signature: ………………… Date: ……..

I voluntarily register myself and authorize SKM BLOOD DONORS Club to contact me for Blood/Blood Component donation as and when desired for any patient undergoing treatment at the hospital.All information will be kept confidential

TO BE FILLED IN BY SKMCH&RC OFFICE ONLY:

Membership No: ………………………….………… Date: ……………………………………………..…… Signature: ………………………….………

Shaukat Khanum Memorial Cancer Hospital & Research Centre7-A, Block R- III, Johar Town, Lahore

Tel: +92 42 3 5945100 Ext. 2366, 2404E-mail: bloodbank@skm.org.pk

Retention Period: 10 Years Filing Location: Marketing & Resource Development Department