Kansas Registry Removal/revocation Form printable pdf download

Kansas Registry Removal/revocation Form

Kansas Registry Removal/Revocation Form

Most of the information on this form is required, so please be sure the form is complete. You will receive an e-mail or

letter confirming your removal, or in the event information needs to be clarified and/or verified. Call toll-free

(888) 744-4531 if you have any questions.

Complete the following information to be removed from the registry.

PARTICIPANT’S NAME

(LAST)

(FIRST)

(MIDDLE)

(SUFFIX)

ADDRESS

(MAILING)

(CITY)

(STATE)

(ZIP CODE)

COUNTY OF RESIDENCE

GENDER

Male

Female

E-MAIL ADDRESS

DATE OF BIRTH

SOCIAL SECURITY NO. or DRIVER LICENSE NO.

(MONTH/DAY/YEAR)

RACE

ETHNICITY

(optional)

White

African American

Asian

Pacific Islander

American Indian or Alaska Native

Other

Latino

Other

INITIAL THE APPROPRIATE CATEGORY

___ I affirm that I am age 18 or over and am able to give full legal authorization.

___ I affirm that I am under the age of 18, an emancipated minor and able to give full legal authorization.

___ I am the parent/guardian of the child being removed from the registry. My relationship to the child is: ________

Please remove my name from the Kansas Organ and Tissue Donor Registry. This is not a refusal to be a donor.

SIGNATURE

DATE

(Parent/Guardian if removing a child)

___ I affirm that I am the person named above and the information provided is true and correct.

WITNESS SIGNATURE

DISINTERESTED WITNESS SIGNATURE

(Required if adult is physically unable to sign

(Only required if adult

due to terminal illness or injury)

is physically unable to sign due to terminal illness or injury)

Fax or mail completed form to:

Phone (888) 744-4531

Midwest Transplant Network

Fax (888) 672-8087

1900 West 47

Place, Suite 400

Westwood, KS 66205

A confirmation will be sent to you.

AU-5 (R0: 1/16)

Kansas Registry Removal/revocation Form

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