Body donor application "*" indicates required fields Name* First Middle Last Street Address* Street Address Address Line 2 City 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 State ZIP Code Phone*Email* Type of Application* Mail Me a Brochure Email Me a Downloadable Brochure Apply Directly Online Number of Brochures*Please enter a number from 1 to 10.Please click “Submit” below and the program office will mail the requested number of brochures to the address provided. Note: Brochures are mailed on a weekly basis.Please click “Submit” below and the program office will email you a downloadable brochure. Note: Brochures are emailed on a weekly basis. This option requires you to print the brochure. Please click “Submit” to receive a confimration email with the Gift of Body to Medical Science Deed of Disposition form. This form must be printed, completed and submitted via the following methods: Mail: Des Moines University Body Donor Program, 8025 Grand Avenue, West Des Moines, Iowa 50266 Email: bodydonor@dmu.edu Fax: 515-271-7014 Once the completed form is received, your application will be processed and a letter of decision will be mailed to you. If the form is not received within 14 days of the application submission, your application will be rejected and no further action will be necessary. Note: A printer is needed for this option. Online ApplicationDate of Birth* Month Day Year Gender* Male Female Current Marital Status* Never Married Married Widowed Divorced Spouse's Name* First Last Main Occupation for Most of Donor’s Life* Donor’s Bussiness or Industry* Donor’s Highest Level of Education Completed* Is the Donor a Veteran?* No Yes Branch of Service* What Is Your Race or Ethnicity?* White African American Hispanic Asian Other Registered Organ/Tissue Donor* Yes No Donor Medical HistoryHeight (Inches)*Weight (Pounds)*Major Health ProblemsIf none, state "None"Surgical HistoryIf none, state "None"Deformities or AmputationsIf none, state "None"Next-of-Kin Contact InformationPrimary Contact Person* Relationship* Primary Contact Address* Street Address Address Line 2 City 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 State ZIP Code Primary Contact Phone*Primary Contact Email Alternate Contact Person* Relationship* Alternate Contact Address* Street Address Address Line 2 City 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 State ZIP Code Alternate Contact Phone*Alternate Contact Email Δ
