Assocation des bénévoles du don de sang Assocation des bénévoles du don de sang

FORM ADHESION AND OFFER A VOLUNTARY HELP TO ABDV

Please, send this form to:

By mail:
Association if Blood Donation Volunteers
1009, Du Vallon road
Sainte-Foy (Québec)
G1V 5C3 		By fax:
(418) 780-2093

General informations:

Family name
__________________________________		 Name
__________________________________

Address
____________________________________________________________		 Apt.
_______

City
______________________________________		 Province
______________

Postal Code
__________ 


Email
__________________________________________________


Home phone : * ( _____ ) _____ - _________
Work phone : ( _____ ) _____ - _________
Cellular phone: ( _____ ) _____ - _________
Fax: ( _____ ) _____ - _________

I am already a volunteer:
Blood donor
Plasma donor
Platelets donor
Blood drive organizer
Blood drive volunteer helper
I would like to volunteer as:
Member of a blood drive organizing committee
Blood donation promoter in my area
Blood drive volunteer helper
Other: Specify
       ________________________
 

Signature: _______________________________________

Date: ____________________

I would like to make a donation to the ABDV Fund in the amount of : $ _________