American Bone Marrow Donor Registry #__________________

CONSENT FORM

A A B B DR DR DQ DQ DRw DRw

I am voluntarily furnishing blood to the American Bone Marrow Donor Registry (ABMDR) for the purpose of determining my HLA type for

compatibility comparison as a possible marrow or stem cell donor, or I am submitting my HLA type information for recording in the American

Bone Marrow Donor Registry files. I understand the need for and the process involved in marrow or stem cell donation. I hereby grant the

ABMDR permission to enter my information and HLA type in its files and to include my HLA type only in Bone Marrow Donors Worldwide

to be compared to patients’ types in this country and worldwide who are viable candidates for marrow transplantation. I further understand that

part of my blood sample may be frozen for the sole purpose of conducting further testing if I am determined to be a first level match with a

patient. I understand that such testing would not be performed without my signed consent. I further understand that my name will be kept

confidential and not released without my written permission. I understand that the only side effects from the sample collection might be some

bruising or redness at the site of the needle insertion.

Donor Name (Please Print) Date / /

Donor Signature Witness Signature

Donor Information (Confidential)

Street Address Apt.#

City State Zip

Phone Home(______) Work: ( )

Fax: ( ) __________________________Email:________________________________________________

D.O.B. / / Sex Spouse First Name

Driver's License: State (_____ ) SS#___________________________________________

Above information used only for the purpose of locating a donors' forwarding address or for cross-checking donor records.

Ethnic origin: (may help in patient/donor matching due to the frequent occurrence of some HLA antigens within certain ethnic groups.)

______Caucasian _______African American _______Native American ________Asian ________Hispanic/Latino

Other (specify) Specific heritage (e.g French, Jewish, Korean) ________________________

Name and address of a relative or close friend who could contact you if we are unable to reach you.

Name__________________________________________________ Spouse name_________________

Address________________________________________________________ Apt#___ ____________

City State Zip_______________

Phone Home( )_____________________________ Work( )______________________________

If you are related to a particular patient, please note relationship and name

Patient Name: _______________________________________ Relationship_____________ ___________

Donor Drive:(if applicable)

PLEASE COMPLETE REVERSE SIDE

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