Authorization for Release of Information and Images Name(Required) First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone(Required)Secondary PhoneEmail(Required) Date of Birth(Required) Month Day Year Current AgeGift 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/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! Drop files here or Select files Accepted file types: jpg, png, pdf, heic, aaeo, doc, xdoc, Max. file size: 1,000 MB, Max. files: 3. Authorization (required)Agreement(Required) 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(Required)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.