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 sptabec@slu.edu.ph
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 sptabec@slu.edu.ph
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 sptabec@slu.edu.ph
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
