LifeShare Donor Registry
Becoming an organ, eye and tissue donor truly shares life with others. The LifeShare Donor Registry allows those who wish to donate life the ability to do so. So, share life today by filling out the registration form below! If you have previously registered on this site, you may modify your records by going to My Profile.

All information submitted will be used only for official registry business, and will be kept completely confidential. We will not share, sell or otherwise compromise this information.

If you have questions about this online form, click on Information. If you have any additional questions or concerns about completing this form, please call (800) 826-LIFE.

First Name
Middle Name
Last Name
Date of Birth
Re-enter Date of Birth

Zip Code
Drivers License #
Re-enter Drivers License #
State ID #
Re-enter State ID #
Telephone Number
(format as: xxx-xxx-xxxx)
Email Address
(requires valid email)
Mother's Maiden Name

Specific Exclusions
The LifeShare Donor Registry will only accept exclusions related to individual organ, eye and tissues that can be removed for purposes of transplantation or research. Distribution of organs are based upon national regulations. See possible exclusions if you need additional brief descriptions of possible organs, eye and tissues that can be used for transplantation and/or research (examples of exclusions are Mandible, Intestine, Vertebral Bodies)

List single exclusions (no narrative):
I offer organ, eye and tissue, with exception to any exclusions listed above, for the following purposes:
Transplant     Both Transplant and Research    

How did you hear about the LifeShare Donor Registry?
Parents or legal guardians will be required to give consent, at the time of donation, for anyone under the age of 18. If you are over the age of 18 at the time of donation, family consent is not required but your family will be notified of your wishes.

» Race (optional)

Native American
Pacific Islander

» Did information from any of these areas influence your decision to register? (optional)

Driver License Office