Application

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Body donor application

Name*
First Middle Last
Street Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email
Which type of application would you like to fill out?*
- Mail me a brochure
- Email me a downloadable brochure
- Apply directly online
How many would you like?*
Please enter a number from 1 to 10.
Please hit the “Submit” button and the program office will mail you the requested amount of application(s) to the address provided. Note: The mailing of application(s) take place on a bi-weekly basis. If you need a faster method to receive the application(s), we encourage you to have the brochure emailed to you or apply directly online.
Please hit the “Submit” button and a confirmation email with the downloadable application will be sent to the email you provided. Note: A printer is needed for this option.
Please hit the “Submit” button and a confirmation email with the Gift of Body to Medical Science Deed of Disposition form will be sent to the email you provided in the application. This form must be printed, completed, and either mailed to the program office or emailed to bodydonor@dmu.edu. Once the program office receives the completed form, 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 Application
Date 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*
In what business or industry was the donor's occupation?*
Highest grade 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
Registered Organ/Tissue Donor*
- Yes
- No
Donor Medical History
Height (inches)*
Weight (pounds)*
Major health problems
If none, state "None"
Surgical history
If none, state "None"
Deformities or amputations
If none, state "None"
Next-of-Kin Contact Information
Primary Contact Person*
Relationship*
Primary Contact Address*
Street Address Address Line 2 City State ZIP Code
Primary Contact Phone*
Primary Contact Email
Alternate Contact Person*
Relationship*
Alternate Contact Address*
Street Address Address Line 2 City State ZIP Code
Alternate Contact Phone*
Alternate Contact Email