Submission Form

First Name:

Last Name:

Email Address:

Street Address:

Street Address 2:

City:

State:

Zip Code:

Phone:

Name of Blood Donor:

Where have you donated blood?
(Eastern Hills, Tonawanda, Southgate, mobile drive, ConnectLife bus):

What first inspired you to donate blood?:

What type of blood have you donated?
(Whole blood, platelets, double red cells):

How would you describe the blood donation process?:

Have you or someone you love ever received blood?:

Where?:

When?:

What do you want people to know that are too scared to donate blood?:

Donating blood with ConnectLife is the only way to ensure your blood stays local for local patients and hospitals, does that influence your decision to donate with us over other blood centers?:

Submit photos of yourself, you with your loved ones, you with your pets, your hobbies, etc. so we can add the photos to your story!

Upload Photo 1:

Upload Photo 2:

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Security code:

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