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Application

Please complete the online form below or download a print and mail a print version. If you have questions, please contact us at 515-271-1481 or by email at bodydonor@dmu.edu.

Please note: Falsification of this application could lead to rejection at the time of death.

Print Application Downloads

Self-Application
Next-of-Kin Application
Power of Attorney for Healthcare Application

Online Application

Additional paperwork will be mailed to the applicant following the submission of this form and all paperwork must be completed and on file at Des Moines University to be considered for the body donor program.

Who is completing this application?*
- Self-applicant
- Legal next of kin applying on behalf of an individual
- Legal power of attorney for healthcare applying on behalf of an individual
Representative Applying on Behalf of Individual
Name of representative applying*
First Last
Address of representative applying*
Street Address Address Line 2 City State ZIP Code
Phone of representative applying*
Relationship of representative applying*
Personal Information Pertinent To Body Donor
Full Name*
Street Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email
Date of Birth*
MM
DD
YYYY
Gender*
- Male
- Female
Current Marital Status*
- Never Married
- Married
- Widowed
- Divorced
Spouse's Full Name*
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
Surgical history
Deformities or amputations
Prolonged medications
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