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Enroll In Mississippi's Donor Registry

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

*An asterisk (*) deontes a required field.

 
*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 (download). 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.

 
*  

 

Donate Life Mississippi Logo

Please fill out the form to register as an organ and tissue donor. By registering as a donor you consent to donate your organs and tissues at the time of your death. Organs and tissues will be recovered for the purpose of transplantation, however, in the event a donated organ or tissue cannot be used for transplant, an effort will be made to use the donation for research.