Authorization for Release of Information

Authorization for Release of Information and Images

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Secondary Phone

Email(Required)

Date of Birth(Required)

Current Age

Gift of Life Affiliation (optional)

What is your connection to donation and transplant?

Donor family member

Living organ donor

Transplant recipient

Patient waiting for a transplant

Family/friend of patient waiting for a transplant

Donation or Transplant professional

Other

You selected "Other" - please describe your connection.

Describe your experience with donation/transplant

Please 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!

Drop files here or

Accepted file types: jpg, png, pdf, heic, aaeo, doc, xdoc, Max. file size: 1,000 MB, Max. files: 3.

Authorization (required)

Signature(Required)

Please type your name below as your digital signature.

Parent/Guardian Signature

If the person above is a minor, a parent or guardian must sign off here.