Donor Registry Enrollment Form (Page 2 of 2) in pdf

Donor Registry Enrollment Form Page 2

Print or type full name of living donor__________________________________________

Mailing Address ___________________________________________________________

City ________________________________State____________Zip _________________

Phone (

) _____________________Date of Birth ______________________________

Driver’s License or ID Card Number ___________________________________________

Social Security Number _____________________________________________________

In the hope that I, ________________________ (name of donor), may help others upon my

death, the following are my directions regarding donation of all or part of my body.

___ On my death, I make an anatomical gift of my organs, tissues, and eyes for any purpose

authorized by law.

___ On my death, I make an anatomical gift of the following specified organ, tissues, or eyes

for any purposes indicated below:

Any or all

Liver

Bone/ligament

Heart valves

Heart

Kidneys

Veins

Skin

Lung

Pancreas

Eyes

Other

Any purpose authorized by law or, specifically as indicated below:

Transplantation

Therapy

Research

Education

Advancement of medical science

Advancement of dental science

Signature of Donor

Date of Birth of Donor

Date Signed

Witness

Date

Witness

Date

DONOR REGISTRY ENROLLMENT FORM

PAGE TWO OF TWO

Donor Registry Enrollment Form Page 2