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Online Registration



 

Ixel Thank you for making the decision to register as a donor. Ixel, shown on the left, is alive today because someone made the decision to say, "Yes."

If you have any questions regarding your registration, please call 1-866-937-8824.


YES! I wish to donate my organs, eyes, and tissues to save or improve someone's life through transplantation.

Examples of organs for transplants include heart, liver, pancreas, kidneys, lungs, and small bowel.

Examples of tissues include eyes/corneas, heart valves, bones, and skin grafts.

Organ and tissue donation still allows for an open casket funeral.

Gender
Male Female
First Name
Middle Name
Last Name
Date of Birth
Address
City
State

Zip Code
Email Address
Phone
Emergency Contact Name
Emergency Contact Phone
Alternate Emergency Phone
Mother's Maiden Name
Drivers License or State ID #

Where did you get information that influenced your decision to register?

  • School
  • Driver License Office
  • Work
  • Media
  • Family/Friends
  • Clinic/Pharmacy
  • Other

By checking this box, you will be given the option of selecting donation limitations upon submission of this form.

If you are under the age of 18, consent must be obtained from your parents or legal guardian at the time of donation. If you are over the age of 18 at the time of donation, family consent is not required, but your family will be notified of your wishes.


» Why Wait? Start Saving Lives Today!
Brick

A living kidney donor saved Brick's life.


If you are between the ages of 17 and 65, and would like more information about the Good Samaritan kidney donation program, please click here.

» Race (optional)

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Pacific Islander
Asian