NORTHVILLE HIGH SCHOOL BLOOD DRIVE Thursday, March 16th, 2017 Auxiliary Gym First Name:

_______________________________________________________

Last Name:

_______________________________________________________

Email Address: _______________________________________________________ Date of Birth:

_______________________________________________________

Mobile Phone:

_______________________________________________________

Select top three (3) preferred donation times below: 7:30 AM

7:45 AM

8:00 AM

8:15 AM

8:30 AM

8:45 AM

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

IF YOU WILL BE SIXTEEN (16) YEARS OLD ON MARCH 16th, 2017, YOU MUST COMPLETE THE PARENTAL CONSENT FORM ON THE FOLLOWING PAGE. A PARENT/GUARDIAN SIGNATURE IS REQUIRED FOR DONATION. IF YOU WILL BE SEVENTEEN (17) OR OLDER ON MARCH 16th, 2017, YOU DO NOT NEED TO COMPLETE THE PARENTAL CONSENT FORM OR OBTAIN A PARENT/GUARDIAN SIGNATURE.

Please return this form and, if required, the signed parental consent form to the NHS Main Office by Friday, March 3rd, 2017. You will receive confirmation of your appointment and donation time no later than Friday, March 10th, 2017. Please contact Student Congress at [email protected] with any questions.