The Living Bank Uniform Anatomical Gift Act Donor Form

For more information about organ/tissue donation, contact The Living Bank at 1-800-528-2971.

The organ and tissue shortage is a crisis, but it is a crisis with a cure. Remember, the only way your family will know your decision is if you tell them.

Donor Name _________________________

Address _______________________________

City/State/Zip_________________________

In the hope that I might help others, I make this anatomical gift, if medically acceptable, to take effect upon my death. I give any needed organs and tissue.

Donor Signature _______________________

Social Security Number_________________

Date __________________________________

Witness #1 ____________________________

Witness #2 ____________________________

Next of Kin ___________________________

Relationship to Donor _________________

Next of Kin Address ___________________

Next of Kin City/State/Zip_____________

Next of Kin Phone(s) __________________

Next of Kin Signature _________________

The Living Bank P.O. Box 6725 Houston, Texas 77265 1-800-528-2971

Mail this filled-out form to the address above. The Living Bank will send you complete information and your donor card to carry with you in the event of an emergency. Feel free to copy and use this form for family members.

____ Check here if you do not want to receive quarterly informational newsletters from the Living Bank.

____ Check here if you would like additional donor registration forms sent to you by The Living Bank. Include a voluntary contribution to cover the cost. Please specify quantity.

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Dedicated to the Memory of Wesley L. Nutten III. May 16, 1929 - August 8, 1993

Mr. Nutten was the first chair of the Organ and Tissue Donation Committee of the American Bar Association, Section of Real Property, Probate and Trust Law, and a kidney transplant recipient

RESOLVED THAT the American Bar Association supports efforts to educate the public about the critical need for organ and tissue donations, and supports efforts to inform the legal community and clients of the opportunities to make these donations.

BE IT FURTHER RESOLVED THAT the American Bar Association urges all attorneys to raise with the clients, when appropriate, the topic of organ and tissue donations and to provide donation forms to those clients who indicate an interest in making a donation.

BE IT FURTHER RESOLVED THAT the American Bar Association urges the legal community to coordinate its efforts with respect to organ and tissue donations with the efforts of the medical community, including doctors, nurses, paramedics, hospitals, organ and tissue registries (in particular, The Living Bank, the only national multi-organ and tissue donor registry), and others involved in organ and tissue transplantation.

Text by Steve Barnill & Company, Inc. Houston, Texas.

Funded in part by a grant from The American College of Trust and Estate Counsel Foundation.