Enroll
In Mississippi's
Donor Registry
 

To enroll in Mississippi's Donor Registry, complete the form below and click the enroll button.

When you enroll in Mississippi's Donor Registry, you are registering as an organ, tissue and
eye donor.

*Note: Fields with an asterisk are required.

Click here to review our privacy statement.
Click here to review THE REVISED MISSISSIPPI UNIFORM ANATOMICAL GIFT ACT.
 
*First Name:  
*Middle Initial:  
*Last Name:  
*Address:  
*City / State / Zip:    
* Date of Birth:
must be at least 18		      
*Driver License/State
 Issued ID Number:		    
Phone Number:
Email Address:  
How did you learn
 about the registry:
*Disclosure statement: By submitting this registration, I affirm that I am the applicant described on this
application, that I am at least eighteen years of age, 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 REVISED MISSISSIPPI UNIFORM ANATOMICAL GIFT ACT.
A document of gift, if not revoked by the donor before death, is irreversible and
does not require the consent of any other person.
It also authorizes any examination necessary to ensure the medical acceptability of
the anatomical gift. 		 
*