Donor Registry Enrollment Form printable pdf download

Donor Registry Enrollment Form

DONOR REGISTRY ENROLLMENT FORM (OPTIONAL)

(name of donor)

INSTRUCTIONS: In addition to completing the references to Anatomical Gifts in your

Living Will and Ohio Health Care Power of Attorney you should also complete and file the

“Donor Registry Enrollment Form” with the Ohio Bureau of Motor Vehicles to ensure that

your wishes concerning organ and tissue donation will be honored. This document will serve

as your consent to recover the organ and/or tissues indicated at the time of your death, if

medically possible. In completing this form, your wishes will be recorded in the Ohio Donor

Registry and will be accessible only to the appropriate organ, tissue or eye recovery organizations.

Be sure to share your wishes in this area with loved ones and friends so they are aware of

your intentions.

To register for the Donor Registry, please complete this form, detach and send the original

to:

Ohio Bureau of Motor Vehicles

ATTN: Record Clearance Unit

P.O. Box 16784

Columbus, Ohio 43216-6784

Make a copy of this form and retain it as part of your Living Will Declaration.

[This form must be signed by two witnesses. If the donor is under the age of 18, a parent or

legal guardian must sign as one of the two witnesses.]

[This form should be used to state your intentions to be included in or removed from the Ohio

Bureau of Motor Vehicles Donor Registry.]

Please indicate below:

____Please include me in the Donor Registry

____Please remove me from the Donor Registry

Ohio State Bar Association

DONOR REGISTRY ENROLLMENT FORM

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Donor Registry Enrollment Form