Authorization for Release of Information and Images Nombre(Requerido) Primero Último Dirección(Requerido) Dirección Línea de dirección 2 Ciudad Estado AlabamaAlaskaSamoa AmericanaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrito de ColumbiaFloridaGeorgiaGuamHawaiIdahoIllinoisIndianaIowaKansasKentuckyLuisianaMaineMarylandMassachusettsMichiganMinnesotaMisisipíMisuriMontanaNebraskaNevadaNew HampshireNew JerseyNuevo MexicoNueva YorkCarolina del NorteDakota del NorteIslas Marianas del NorteOhioOklahomaOregónPensilvaniaPuerto RicoRhode IslandCarolina del SurDakota del SurTennesseTexasUtahIslas Vírgenes de EE.UUVermontVirginiaWashingtonVirginia del OesteWisconsinWyomingFuerzas Armadas de las AméricasFuerzas Armadas de EuropaFuerzas Armadas del Pacífico Código postal Primary Phone(Requerido)Secondary PhoneCorreo electrónico(Requerido) Date of Birth(Requerido) Month Day Año Current AgeGift of Life Affiliation (optional)What is your connection to donation and transplant? Donor family member Living organ donor receptor de trasplante Patient waiting for a transplant Family/friend of patient waiting for a transplant Donation or Transplant professional Otro You selected "Other" - please describe your connection.Describe your experience with donation/transplantPlease share more details about your connection. Donor families, please tell us about your loved one who donated - name, age, interests, were they on the Donor Registry? Transplant patients and recipients, tell us about your transplant journey. What type of transplant? How long have you been waiting or did you wait? Recipients, when and were did you have your transplant? Photo submission (optional)Feel free to share a photo with us!Feel free to share a photo with us! Suelta los archivos aquí o Seleccione archivos Tipos de archivos aceptados: jpg, png, pdf, heic, aaeo, doc, xdoc, Max. tamaño de archivo: 1,000 MB, Max. archivos: 3. Authorization (required)Agreement(Requerido) I hereby grant Gift of Life Michigan and its designees permission to share my story, photos or videos in all education programs and publications, with traditional media, on social media, on websites and any other means of promoting organ, eye and tissue donation to help save and heal lives.Signature(Requerido)Please type your name below as your digital signature.Parent/Guardian SignatureIf the person above is a minor, a parent or guardian must sign off here.
