Body donor application Name* First Middle Last Street Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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, submitted via the following methods: Mail: Des Moines University Body Donor Program, 3200 Grand Avenue Des Moines, Iowa 50312 Email: bodydonor@dmu.edu Fax: 515-271-7014 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 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* 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 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Alternate Contact Phone*Alternate Contact Email Δ
