Register for the Public Cord Blood Bank

Volunteer form

*Required field

Baby’s mother
Please enter your first and last names as they appear on your health insurance card from the RAMQ. First name: Family name: Date of birth: Your ethnic origin: Arab Central Asian North Asian Northeast Asian South Asian Southeast Asian Caucasian (White) Chinese African Black Caribbean Black Black - other Filipino First Nations Hispanic Inuit Ashkenazi Jew Sephardic Jew Métis Pacific Islander Other
Address
No.: Street: Apt.: City: Province: Québec Postal code: Telephone (home): Telephone (work): ext. Cell. phone: Email address: Are you moving? Yes No If yes, please fill out our change of address form by clicking here.
*Baby’s father
First name: Family name: *Father’s ethnic origin: Arab Central Asian North Asian Northeast Asian South Asian Southeast Asian Caucasian (White) Chinese African Black Caribbean Black Black - other Filipino First Nations Hispanic Inuit Ashkenazi Jew Sephardic Jew Métis Pacific Islander Other
*Information about the pregnancy
Are you pregnant with more than one baby (e.g., twins, triplets...)? Yes No Is a Caesarean planned? Yes No Expected delivery date: Hospital where you will be giving birth: *Name of the attending physician:
Consent for registration in the Public Mothers’ Milk Bank
I would also like to register in the Public Mothers’ Milk Bank: Yes No I have read the Consent to Human Milk Donation. I, acknowledge on having read and understood the information contained in the registration form to the Public Mothers’ Milk Bank and the Consent to human milk donation. I have had the opportunity to ask a Héma-Québec representative all my questions and have received satisfactory answers. I understand that it is important that I inform Héma-Québec of any changes in my health status. I understand that Héma-Québec reserves the right to contact me, if necessary, for any medical reason related to my health, that of my child or that of the recipient. I understand that if my donation does not qualify for the Public Bank, I can consent to donate it to support research projects approved by an ethics board. If my donation does not qualify for banking, I would like it to be used for research on human milk: Yes No I certify that the information provided is complete and accurate to the best of my knowledge.
*CONSENT TO REGISTRATION IN THE PUBLIC CORD BLOOD BANK
I have read the Consent to Cord Blood Donation. I, acknowledge on having read and understood the information regarding registration in the Public Cord Blood Bank and the Consent to Cord Blood Donation. I have had the opportunity to ask a Héma-Québec representative all my questions and have received satisfactory answers. I understand that it is important that I inform Héma-Québec of any changes in my health status and notify Héma-Québec if my child develops an immune or blood disease. I understand that Héma-Québec reserves the right to contact me, if necessary, for any medical reason related to my health, that of my child or that of the recipient. I understand that if my donation does not qualify for the Public Cord Blood Bank, I can consent to donate it to support research projects approved by an ethics board. *If my donation does not qualify for banking, I would like it to be used for research on cord blood: Yes No I certify that the information provided is complete and accurate to the best of my knowledge.