ST.

LOUIS UNIVERSITY
NATIONAL SERVICE TRAINING PROGRAM(NSTP)OFFICE
SCHOOL OF TEACHER EDUCATION
Gonzaga Campus, Gen. Luna Rd.,
2600 Baguio City
Tel: (074) 4470664/09198807387/09163349807
Email: nstpcoor@slu.edu.ph; slunstp@yahoo.com

MEDICAL-NUTRITIONAL HEALTH APOSTOLATE

BLOOD SERVICES PROGRAM

STUDENT BLOOD TYPE CERTIFICATION FORM

(note: please accomplish in duplicate copies)

Name: ___________________________________Course/Year:______________SLU ID No:_____________

Date of Birth: __________________ Place of Birth:_______________________________________________
Age: ________________Gender:________________
Permanent Home Address: __________________________________________________________________
Baguio City/Temporary Residential/Boarding House Address:_______________________________________
Telephone Number: ______________________Cell phone/Mobile phone Number:______________________
Signature of Student:____________________________________

This is to certify that the blood type of the above student is ________as per blood typing procedure
administered by the office/clinic/agency specified below.

_________________________ ____________________________
Printed Name and Signature Printed Name and Signature
Administering Medical Technologist Head of Administering Agency/Office
or Authorized Signatory

Date: ______________________ Date: _______________________

Name of Administering Agency:_______________________________________________________________

Address:_____________________________________________Contact Number:__________________

*******************************************to be filled up by the NSTP Office****************************

Date Submitted:_________________________Received by:_______________________________________

Remarks:________________________________________________________________________________

I AM A LOUISIAN …SERVING WITH A MISSIONARY HEART

LOUISIAN TAYO…TAYO MISMO