| Giving Blood - LifeSaver Enrollment Form |
|
Print this page and then fill it out and mail to the address at the bottom of the page.
| Name | Date | |
| Address | ||
| City | State | Zip |
| Soc. Sec. No. | DOB | |
| Home Phone |
Family Physician |
|
| If you are protected by a Blood Bank of Delmarva membership, please specify membership name and number. | ||
| Membership Name |
Membership Number |
|
| Have you ever given blood before? [ ] Yes [ ] No | |
| I am available to donate: | [ ] Anytime [ ] 8:00am to 5:00pm [ ] 5:00pm to 8:00pm |
| I would be willing to donate: | [ ] Once a year [ ] Twice a year [ ] Three or more times a year |
| Preferred Donation Site: | [ ] Christiana [ ] Dover [ ] Wilmington [ ] Salisbury [ ] Mobile site (please specify:___________ |
| Blood type | Signature |
Note: This is NOT an enrollment form for Blood Bank membership.
Please mail this form to:
Blood Bank of Delmarva
100 Hygeia Drive
Newark, DE 19713