{"id":11431,"date":"2026-01-20T10:24:38","date_gmt":"2026-01-20T10:24:38","guid":{"rendered":"https:\/\/amcenetstg.wpengine.com\/?page_id=11431"},"modified":"2026-01-20T11:49:26","modified_gmt":"2026-01-20T11:49:26","slug":"donate-blood","status":"publish","type":"page","link":"https:\/\/www.amce.net\/fr\/donate-blood\/","title":{"rendered":"Blood Donation Drive \u2013 Interest Sign\u2011Up Form"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"11431\" class=\"elementor elementor-11431\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\">\n\t\t\t\t        <section class=\"elementor-section elementor-top-section elementor-element elementor-element-69561e6 elementor-section-boxed elementor-section-height-default elementor-section-height-default pxl-row-scroll-none pxl-zoom-point-false pxl-section-overflow-visible pxl-section-fix-none pxl-bg-color-none pxl-section-overlay-none exad-glass-effect-no exad-sticky-section-no\" data-id=\"69561e6\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\n                \n                <div class=\"elementor-container elementor-column-gap-default\">\n                <div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ed879a2 pxl-column-none pxl-column-overflow-hidden-no exad-glass-effect-no exad-sticky-section-no\" data-id=\"ed879a2\" data-element_type=\"column\" data-e-type=\"column\">\r\n        <div class=\"elementor-widget-wrap elementor-element-populated\">\r\n                     \r\n        \t\t<div class=\"elementor-element elementor-element-7c2eb3d exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-pxl_heading\" data-id=\"7c2eb3d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"pxl_heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n<div id=\"pxl-pxl_heading-7c2eb3d-7035\" class=\"pxl-heading px-sub-title-default-style\">\n\t<div class=\"pxl-heading--inner\">\n\t\t\n\t\t<h3 class=\"pxl-item--title style-default  highlight-default\" data-wow-delay=\"ms\">\n\t\t\t\t\tBlood Donation Interest Sign-Up Form\t\n\t\t\t\n\t\t<\/h3>\n\t\t\n\t<\/div>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t            <\/div>\r\n        <\/div>\r\n        \t\t\t<\/div>\n\t\t<\/section>\n\t\t        <section class=\"elementor-section elementor-top-section elementor-element elementor-element-63b60ca elementor-section-boxed elementor-section-height-default elementor-section-height-default pxl-row-scroll-none pxl-zoom-point-false pxl-section-overflow-visible pxl-section-fix-none pxl-bg-color-none pxl-section-overlay-none exad-glass-effect-no exad-sticky-section-no\" data-id=\"63b60ca\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\n                \n                <div class=\"elementor-container elementor-column-gap-default\">\n                <div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ec175ca pxl-column-none pxl-column-overflow-hidden-no exad-glass-effect-no exad-sticky-section-no\" data-id=\"ec175ca\" data-element_type=\"column\" data-e-type=\"column\">\r\n        <div class=\"elementor-widget-wrap elementor-element-populated\">\r\n                     \r\n        \t\t<div class=\"elementor-element elementor-element-9e808f8 exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-pxl_contact_form\" data-id=\"9e808f8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"pxl_contact_form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t    <div class=\"pxl-contact-form pxl-contact-form1 btn-w-auto\" data-wow-delay=\"ms\">\r\n        \n<div class=\"wpcf7 no-js\" id=\"wpcf7-f11430-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"11430\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/11431#wpcf7-f11430-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/fr\/wp-json\/wp\/v2\/pages\/11431#wpcf7-f11430-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"11430\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f11430-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"uacf7-form-11430\"><label> Your name\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/label>\n\n<label> Your email\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" autocomplete=\"email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n\n<label>Date of Birth\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"date-of-birth\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Select your date of birth\" value=\"\" type=\"date\" name=\"date-of-birth\" \/><\/span>\n<\/label>\n\n<label>Phone Number\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"phone-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Enter your phone number\" value=\"\" type=\"tel\" name=\"phone-number\" \/><\/span>\n<\/label>\n\n<label>Location\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-843\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-843\" \/><\/span>\n<\/label>\n\n<!-- ============================= -->\n<!-- Eligibility & Health Screening -->\n<!-- ============================= -->\n\n<h3>Eligibility &amp; Health Screening (Pre\u2011Assessment)<\/h3>\n\n<label>Have you donated blood before?\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-912\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-912[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-912[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/label>\n\n    <label>If yes, when was your last donation?\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"last-donation\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" placeholder=\"Select date\" value=\"\" type=\"date\" name=\"last-donation\" \/><\/span>\n    <\/label>\n\n<hr>\n\n<label>Are you currently on any medication?\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-33\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-33[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-33[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/label>\n\n    <label>If yes, please specify:\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"medication-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"List medication name(s), dosage, and frequency\" name=\"medication-details\"><\/textarea><\/span>\n    <\/label>\n\n\n<hr>\n\n<label>Do you have any known medical conditions?\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-485\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-485[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-485[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/label>\n\n    <label>If yes, please specify:\n      <span class=\"wpcf7-form-control-wrap\" data-name=\"condition-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"E.g., hypertension, diabetes, allergies, etc.\" name=\"condition-details\"><\/textarea><\/span>\n    <\/label>\n \n<hr>\n\n<label>Have you experienced any of these in the past 14 days?\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-933\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-933[]\" value=\"Fever\" \/><span class=\"wpcf7-list-item-label\">Fever<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-933[]\" value=\"Infection\" \/><span class=\"wpcf7-list-item-label\">Infection<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-933[]\" value=\"Recent surgery\" \/><span class=\"wpcf7-list-item-label\">Recent surgery<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-933[]\" value=\"None of the above\" \/><span class=\"wpcf7-list-item-label\">None of the above<\/span><\/label><\/span><\/span><\/span>\n<\/label>\n\n\n<h3>Additional Information<\/h3>\n<label>Emergency Contact Name\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Full name of emergency contact\" value=\"\" type=\"text\" name=\"emergency-contact-name\" \/><\/span>\n<\/label>\n\n<label>Emergency Contact Phone\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tel-816\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" autocomplete=\"tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"tel-816\" \/><\/span>\n<\/label>\n\n<label>Do you have any questions or special needs?\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"questions-special-needs\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Tell us about accessibility needs, or questions\" name=\"questions-special-needs\"><\/textarea><\/span>\n<\/label>\n\n<h3>Consent<\/h3>\n\n<label>Consent\n<span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-169\"><span class=\"wpcf7-form-control wpcf7-acceptance optional\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-169\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">By submitting this form, I confirm that the information provided is accurate and that I am willing to participate in the blood donation drive, subject to final medical screening.<\/span><\/label><\/span><\/span><\/span> \n<\/label>\n\n\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"fr\"\/><\/form>\n<\/div>\n        <div id=\"qrcode\" class=\"hide-qr\"><\/div>\r\n    <\/div>\r\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t            <\/div>\r\n        <\/div>\r\n        \t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Blood Donation Interest Sign-Up Form Your name Your email Date of Birth Phone Number School Eligibility &amp; Health Screening (Pre\u2011Assessment) Have you donated blood before? YesNo If yes, when was your last donation? Are you currently on any medication? YesNo If yes, please specify: Do you have any known medical conditions? YesNo If yes, please [&hellip;]<\/p>","protected":false},"author":5,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-11431","page","type-page","status-publish","hentry"],"featured_image_src":null,"featured_image_src_square":null,"_links":{"self":[{"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/pages\/11431","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/comments?post=11431"}],"version-history":[{"count":0,"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/pages\/11431\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.amce.net\/fr\/wp-json\/wp\/v2\/media?parent=11431"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}