Confirmation of Contract Cancellation - Over 16

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 discarded and will not be available for use for any purpose should I require it under any circumstances in the future. - I am over 16 years of age.

Name:(Required)

First Last

CK Number:(Required)

Date of Birth:(Required)

Additional Contact

Please provide the details for an additional contact ie. parent

Name:(Required)

First Last

Phone:(Required)

Email:(Required)

Secondary Additional Contact

If relevant, please provide the details for a secondary additional contact ie. parent

Name:

First Last

Phone:

Email:

Confirmation

I give notice of cancellation of this contract with CordBank.

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

I am over the age of 16 and confirm that the cord blood I am requesting to be destroyed is my own.