1.1 I confirm that I am 18 years or older and that I am legally and mentally able and competent to provide consent as envisaged in this document.
1.2 I fully understood the information that was provided to me prior to signing this consent from. Any and all questions I asked were answered to my satisfaction and further information has been provided to me on my request. I therefore acknowledge that I am fully informed about all relevant factors relating to cord blood/tissue/cells donation to enable me to give consent in respect of this consent form.
1.3 I understand that the cord blood and cells derived from my baby’s umbilical cord blood and tissue, may be used for transplantation and/or cell therapy in a patient unknown to me, anywhere in the world, in accordance with my or my child’s specific consent in this regard.
1.4 Both the details of the donor of the blood/tissue and the patient will remain anonymous.
1.5 I confirm that I have completed my Medical History to the best of my knowledge and that the information contained therein is accurate, true and correct.
1.6 I agree to the taking of non-invasive buccal samples from my child for HLA typing involving DNA analysis.
1.7 I agree to have my child’s buccal samples stored for future use in further HLA typing at the discretion of The Sunflower fund.
1.8 I consent to my special personal information and other personal data, which includes my child’s HLA results, being stored safely and securely by The Sunflower Fund in the electronic database of The Sunflower Fund. I consent to my special personal information and other personal data being transferred outside the borders of the Republic of South Africa in encrypted form, provided that such information will be subject to data security measures and privacy regulations similar to those prescribed by South African Law.
1.9 I understand consent to my special personal information and other personal data being submitted to international stem cell registries, exclusively in encoded form and that this information and data may be used by The Sunflower Fund and stem cell registries in other countries in search of a suitable stem cells donor for patients worldwide.
1.10 I agree and undertake to communicate any changes to my personal information as soon as reasonably possible to The Sunflower Fund to enable them to keep their databases updated with accurate, recent and correct information.
1.11 I understand and accept that no financial gain will be forthcoming to myself or my child should the harvested stem cells be donated to any matching patient.
1.12 I understand and accept that I have the right to withdraw my consent at any time and to instruct The Sunflower Fund to remove, delete and/or destroy all information and data about me or my child, be it identified or de-identified, from all relevant stem cell registries, as soon as reasonably possible, and provide me with written confirmation by the person in charge of the registries that this has been done.
2. By completing this form, I give permission to the:
2.1 Collection and storage of all the special personal information on this form, including any genetic information resulting from my testing, on a safe and secure database, subject to data security measures and privacy safeguards required in terms of South African Law;
2.2 Release of encoded special personal and genetic information to The Sunflower Fund and any affiliated international bone marrow, stem cell donor, cord blood unit registries, any transplant centres and to the listing of my special persona information and personal data in the worldwide Search and Match Services database for the purposes of determining a possible match with potential stem cell transplant recipients;
2.3 Authorised laboratories and/or registries, including but not limited to, The Sunflower Fund, to make use of any of my samples to do further extended testing at the discretion and request of The Sunflower Fund;
2.4 Use of my de-identified special personal and genetic information for research, historical and statistical purposes by external third parties as authorized and approved by The Sunflower Fund. I understand and accept that further research, historical or statistical results generated and/or collected and/or analyzed by such third parties will not be communicated to me directly, which may include the publication of research findings in local and/or international media resulting from the usage of my de-identified special personal and genetic information.
3. Please select: