Confirmation of Contract Cancellation

In order to formally end the contract, and for security purposes, you need to provide the following information. - I give notice of cancellation of this contract with CordBank. - I understand that the cord blood will be returned and will not be available for use for any purpose should I or my child require it under any circumstances in the future. - I am the legal guardian(s) of the child whose blood is stored by CordBank under this contract. - My child is under 16 years of age.

Child's Name(Required)

First Last

Child's CK number:(Required)

Child's Date of Birth:

Parent/Legal Guardian Details

Name:(Required)

First Last

Phone:(Required)

Email:(Required)

Parent/Legal Guardian

Parent/Legal Guardian 2:

First Last

Parent/Legal Guardian 2 Phone:

Parent/Legal Guardian 2 Email:

We/I give notice of cancellation of this contract with CordBank.

We/I I understand that the cord blood will be destroyed and will not be available for use for any purpose should I or my child require it under any circumstances in the future.

We/I am the legal guardian(s) of the child whose blood is stored by CordBank under this contract.

The child is under 16 years of age.