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NY Organ Donor Enrollment Form

This document is an enrollment form for the New York State Donate Life Registry. By completing and submitting this form, an individual consents to donate their organs, tissues, and eyes in the event of their death. The form requests identifying and contact information and specifies which organs and tissues the individual wishes to donate. Signing and submitting the form enrolls the individual in the registry and provides legal consent for organ and tissue donation upon their death.

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Aleksandr Kiliyevich
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21 views1 page

NY Organ Donor Enrollment Form

This document is an enrollment form for the New York State Donate Life Registry. By completing and submitting this form, an individual consents to donate their organs, tissues, and eyes in the event of their death. The form requests identifying and contact information and specifies which organs and tissues the individual wishes to donate. Signing and submitting the form enrolls the individual in the registry and provides legal consent for organ and tissue donation upon their death.

Uploaded by

Aleksandr Kiliyevich
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

New York State Donate Life Registry Enrollment Form

donatelife.ny.gov | 1-866-NY-DONOR

Organ, eye, and tissue donors save and heal lives. By enrolling in the New York State Donate Life Registry, you consent to donate
organs and tissues in the event of your death. If you are being considered as a donor at age 16 or 17, your parents or legal
guardians are alerted to your registration and have the final say regarding whether your donation can proceed.
*Indicates required field. Please type or print clearly in black or blue ink:
IDENTIFYING INFORMATION

_________________________________________________ _____ ________________________________________________________________


*Name: (First) (MI) *(Last)
________/________/____________ (MM/DD/YYYY)
*Date of Birth
_____________________________________________________________ OR ____________________________________________________________
NYS DMV Identification Number (9 Digit License/Permit/Non-Driver ID #) IDNYC Number

CONTACT INFORMATION
We will confirm your registration by email, if provided, or U.S. mail

___________________________________________________ ______________________________________ __________ _______________


*Mailing Address *City *State *Zip Code
_________________________________________________________________________ (_________) _________ - _______________
Email Address Phone

SPECIFICATIONS
*I CONSENT TO THE DONATION OF
☐ All my organs, tissues and eyes; or
☐ Only the organs and tissues checked: Organs: ☐ Heart ☐ Kidneys ☐ Liver ☐ Lungs ☐ Intestines ☐ Pancreas
Tissues: ☐ Blood vessels ☐ Bone and Connective Tissue ☐ Corneas ☐ Eyes ☐ Skin

*I CONSENT TO DONATE MY ORGANS AND/OR TISSUE FOR THE PURPOSE(S) OF:


☐ Transplant and Research◊ ☐ Transplant Only ☐ Research◊ Only
◊Research: Every effort will be made to help save and heal the lives of patients in need of transplants through your gift of organ and tissue donation. If
organs and/or tissues are not suitable for transplant, registrants consenting to research authorize their use for research and education that may lead to
new treatments or cures.

SIGN AND DATE


By signing below, I am consenting to enroll in the New York State Donate Life Registry. 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 access to this information
as needed for the administration of the Registry and to federally regulated organ procurement organizations, New York State licensed tissue and
eye banks at or near the time of my death and entities formally approved by the NYS Commissioner of Health.

________________________________________________________________________________ ________/________/____________
*Signature *Date

Complete, sign and date this form. Submit to NYS Donate Life Registry by email: registry@donatelife.ny.gov or U.S. Mail to:
New York State Donate Life Registry, 185 Jordan Road, Troy, New York 12180

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