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Donate Life Organ and Tissue Donor Registry Enrollment Form
* Require completion--Please print clearly
Name:
*First: _____________________________ *Last: ____________________________ MI: ________ Suffix: ____________
*Date of Birth: Month: ______/Day: ______/Year: _________ * Gender: Male: ______ Female: _______
*Address: __________________________________________City: __________________State: ________Zip: __________
*Phone Number: (____) ______________________ Email address: ________________________________________
*Height: Feet: _______ Inches: _______ *Eye color: _______________
*Identification Number: (One of the below is required)
DMV Driver’s or Non-Driver’s License Number (9 digits): ____________________________________________________
NYCID Number: _____________________________________________________________________________________
* I offer the donation of:
All organs, tissues and eyes
Limited organs, tissues and eyes as checked below:
Bone and connective tissue
Liver (with iliac vessels)
Corneas
Lungs
Eyes
Pancreas (with iliac vessels)
Heart (for valves)
Skin
Heart and connective tissue
Small intestine
Kidneys
Veins
* I wish to donate my organs and/or tissues for the purpose(s) of:
Transplantation and Research Transplantation only Research only
I wish to enroll in the New York State Donate Life Organ and Tissue Donor Registry maintained by the New York State
Department of Health. I understand that by enrolling in the registry I am giving legal consent to the donation of my organs
tissues and eyes (as specified above) in the event of my death. I authorize the NYS Department of Health to access this
information as needed in administration of the registry, and to share this information at or near the time of my death with
federally regulated organ procurement organizations, New York State licensed tissue and eye banks and entities formally
approved by the Commissioner.
*Signature: _____________________________________________________________ Date: _____/_____/_____
Please complete form and mail to:
NYS Department of Health, Organ Donation and Transplant Unit, 875 Central Avenue, Albany, NY 12206 or
email to: donorreg@health.ny.gov