Donor Registry Form 2 millioin registered donors
 

*First Name: Phone Number: ) -
Middle Initial:
*Last Name: *City:

*Gender:

*State:
Ethnicity: *Zip Code:
*Date of Birth: / /
(mm/dd/yyyy)
*Email Address:
*How did you hear about us? If other, please list:

 

 
In order to complete the electronic signature, please fill out the last four digits of your SSN and type your name in the signature field. All information submitted will be used only for official Registry business and will be kept completely confidential. We will not share, sell or otherwise compromise this information. As further validation, you may include your Driver's License number or state issued ID card number.
Driver's Lic#/or ID#: (optional)
 
*Signature: *Date:
(*) Indicates required information.  
For more information, call 800.521.GIVE or you may email us at info@donatelifela.org.
After submission, you will receive an email containing a copy of your registration which will confirm your registration and it can be printed or saved for your records.


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