First Name
Middle Name
Last Name
Gender		Male      Female
Date of Birth		(01) January (02) February (03) March (04) April (05) May (06) June (07) July (08) August (09) September (10) October (11) November (12) December   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Re-enter Date of Birth		(01) January (02) February (03) March (04) April (05) May (06) June (07) July (08) August (09) September (10) October (11) November (12) December   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Address
City
State		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington,D.C. West Virginia Wisconsin Wyoming
Zip Code
Drivers License #
Re-enter Drivers License #
State ID # (optional)
Re-enter State ID #
Telephone Number (format as: xxx-xxx-xxxx)
Email Address (requires valid email)
Mother's Maiden Name
Specific Exclusions The LifeShare Donor Registry will only accept exclusions related to individual organ, eye and tissues that can be removed for purposes of transplantation or research. Distribution of organs are based upon national regulations. See possible exclusions if you need additional brief descriptions of possible organs, eye and tissues that can be used for transplantation and/or research (examples of exclusions are Mandible, Intestine, Vertebral Bodies) List single exclusions (no narrative):
I offer organ, eye and tissue, with exception to any exclusions listed above, for the following purposes: Transplant     Both Transplant and Research
How did you hear about the LifeShare Donor Registry?
- Select - Newspaper Radio Word of mouth Other OU OSU Health Department
Parents or legal guardians will be required to give consent, at the time of donation, for anyone under the age of 18. 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.