Cancel
Your Registry
Enrollment
 

To cancel your enrollment in Mississippi's Donor Registry, complete the form below and click the send cancellation button.

Please include a phone number where you may be reached between the hours of 8 AM to 5 PM Monday through Friday to confirm the cancellation of your enrollment.

*Note: Fields with an asterisk are required.

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*First Name:  
*Middle Initial:  
*Last Name:  
*Address:  
*City / State / Zip:    
*Date of Birth:      
*Driver License/State Issued ID Number:    
*Phone Number:    
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