DONOR REGISTRY ENROLLMENT FORM

First Name Middle Name Last Name

INSTRUCTIONS:  In addition to completing the references to Anatomical Gifts in your Living Will and Ohio Health Care Power of Attorney, you should also complete and file the “Donor Registry Enrollment Form” with the Ohio Bureau of Motor Vehicles to ensure that your wishes concerning organ and tissue donation will be honored.  This document will serve as your consent to recover the organ and/or tissues indicated at the time of your death, if medically possible.  In completing this form, your wishes will be recorded in the Ohio Donor Registry and will be accessible only to the appropriate organ, tissue or eye recovery organizations.  Be sure to share your wishes in this are with loved ones and friends so they are aware of your intentions.

To register for the Donor Registry, please complete this form, detach and send the original to:

            Ohio Bureau of Motor Vehicles

            ATTN:  Record Clearance Unit

            P.O. Box 16784

            Columbus, Ohio  43216-6784

Make a copy of this form and retain it as part of your Living Will Declaration.

Please indicate below:

_____  Please include me in the Donor Registry.

_____  Please remove me from the Donor Registry.

First Name Middle Name Last Name

Contact Address

Contact Phone Number

Date of Birth  Contact Title

Social Security Number   Contact Company Name

Driver’s License or ID Card Number   

In the hope that I, First Name Middle Name Last Name, may help others upon my death, the following are my directions regarding donation of all or part of my body.

_____  On my death, I make an anatomical gift of my organs, tissues, and eyes for any purpose authorized by law

OR

_____  On my death, I make an anatomical gift of the following specified organ, tissues, or eyes for any purpose indicated below:

q Any or all	q Liver	q Bone/ligament	q Heart valves
q Heart	q Kidneys	q Veins	q Skin
q Lung	q Pancreas	q Eyes	q Other

q Any purpose authorized by law or, specifically as indicated below:

q Transplation

q Therapy

q Research

q Education

q Advancement of medical science

q Advancement of dental science

Signature of Donor

Date of Birth of Donor                                                  Date Signed

Witness                                                                                    Date

Witness                                                                                    Date