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TSBC - Donor Application

All fields are required.

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Profession:
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Name of college attended, if any:
Are you a citizen of the United States?: YesNo
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Are you able to make a commitment to donate at least once a week at our Berkeley office for one year? (You must visit during lab hours, Monday through Thursday, 8:00am to 3:00pm and Friday, 8:00am to 2:00pm):Yes No

Family and Medical Information

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Are you in touch with both of your biological parents?: Yes No

Have you, or has anyone in your family, including your siblings, parents, aunts, uncles, first cousins and grandparents, ever had any of the following?:
Diabetes (Type 1 or Type 2) Yes No
Heart Disease, Heart Attack, or High Blood Pressure Yes No
Stroke Yes No
Cancer Yes No
Mental Illness (Bi-Polar, Schizophrenia, Depression, etc.) Yes No
Genetic Diseases (Alzheimer's, Sickle Cell Carrier, etc.) Yes No
Birth Defects (spina bifida, cleft palate, heart malformation, etc.) Yes No
Alcoholism or Substance Abuse Yes No
Do you drink alcohol? Yes No
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Have your sexual partners in the past five years been: Men Women Both
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