YES! I wish to donate my organs, tissues, and eyes to save or enhance someone's life through transplantation.
First Name is required.
First Name*
Middle Name is Required.
Middle Name
Last Name is required.
Last Name*
Mother's Maiden Name is Required.
Mother's Maiden Name*
Drivers License Number/State ID# is required.
Driverís License Number/ ID #*
Address is required.
Most Recent Address*
City is required.
City*
State is required.
State*
Zip is required.
Zip Code*
Birth Date is required.
Date of Birth*
Gender is required.
Gender*
Ethnicity
Phone
Invalid Email Address
Email Address
Required
Password*
(Retype Password*)
Passwords must be 6 characters long.
Donation Limitations Would you like to specify donation limitations? A donation limitation is a particular donation you wish to exclude from the Registry and explicitly states you do NOT give your legal authorization for those organs, tissues, and eyes to be recovered. Limitations may include: heart, lungs, liver, kidneys, pancreas, intestine, eyes/cornea, skin grafts, heart for valves, and bones.

Yes, I would like to specify limitations for my donation.
Terms and Conditions By submitting this registration I affirm that I am the applicant described on this application and that the information entered herein is true and correct to the best of my knowledge. This registration will serve as a document of gift as outlined in the Georgia Uniform Anatomical Gift Act. A document of gift, not revoked by the donor before death, is irreversible and does not require the agreement of any other person. It also authorizes any examination necessary to ensure the medical acceptability of the anatomical gift.
Terms and conditions must be accepted.

Yes, I accept the Terms and Conditions.