Leukopak Donor Program Intake Form

Thank you for your interest in our Specialized Donor Program! By filling out this form, you are confirming you would like to be contacted to learn more about the program and schedule a prescreen appointment.^ Complete the form below and after submission allow up to 7-10 days for a Red Cross team member to call you. Appointments can also be made by calling 1-833-595-2214. *Please note, a phone number is required because all prescreen appointments are scheduled over the phone with a Red Cross team member.
First Name
Last Name
Email
Preferred Phone Number*
Phone Type
Select Your Location Preference
How did you learn about the program?
Would you like to opt in to receive text messages?
By opting in you are agreeing to receive texts from the Red Cross. Message and data rates my apply. For more information visit the text opt in page by clicking here. **You will be paid with a gift card at the time of prescreen or collection, or a check will be mailed to your home following the appointment. By submitting this form you are agreeing to our privacy policy.

	Looking for more information?LEARN MORE >> Looking for the Red Cross Blood Donor website?VISIT NOW >>
	^A prescreen appointment is an in-person appointment and takes approximately 45-60 minutes. During your prescreen appointment a Red Cross staff member will ask a series of questions to determine if you meet the health requirements for participation and samples of blood will be drawn for testing purposes. You will be compensated $50 for a prescreen visit. Individuals between the ages of 18-64, weigh between 110 and 500 pounds, and are in general good health may be eligible to participate in the Specialized Donor Program. If you qualify as an eligible candidate, your prescreen results will be valid for 90 days. If you are not contacted to give a collection within those 90 days, we may contact you to schedule another prescreen visit. You will be compensated $50 for each prescreen visit.