Mississippi's Valued Platelet Enrollment Form

Please fill out the information to request to be enrolled into Mississippi's Valued Platelet program. Please click the "Request Enrollment" button to submit your application.

Once you completed the form a blood center employee will verify your information and you'll recieve an email once your status is approved
* Denotes the field is required
First Name:*
Last Name:*
Home Phone:*
Work Phone:
Birth Date:* /  /  Year (4 digits)
Email:*
Address 1:*
Address 2:
City:*
State:*
Zip:*
 

Donation information may not be updated for at least seven days.