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 number of brochure(s) to the address provided. Note: The mailing of the brochure(s) take place on a weekly basis.

Please hit the “Submit” button and the program office will e-mail you the downloadable brochure. Note: E-mailing of the downloadable brochure will take place on a weekly basis. 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 Application

Date of Birth*

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?*

Yes

Branch of service*

What is your race or ethnicity?*

Registered Organ/Tissue Donor*

Yes

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

Body donor application

Online Application

Donor Medical History

Next-of-Kin Contact Information

Contact DMU

Address