Required fields are marked with an asterisk (*).

First Name is required.
Middle Name is Required.
Last Name is required.
Birth Date is required.
Gender is required.

Place of Birth is required.
Address is required.
City is required.
State is required.
Zip is required.
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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 consent for those organs, tissues and/or eyes to be recovered. Limitations may include: heart, lungs, liver, kidneys, pancreas, intestine, eyes, corneas, skin grafts, heart for valves, bones and soft tissue (i.e., tendons).

Terms and Conditions

By submitting this registration I affirm I am the person described on this application, and 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 Florida Uniform Anatomical Gift Act. A document of gift, 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.

Terms and conditions must be accepted.
In order to proceed, you must click both the Terms and Conditions AND the "I'm am not a robot" checkboxes. The Electronic Signature Certification is your legal acknowledgement of registration. The "I'm not a robot" checkbox is an extra security feature that helps safeguard data. Both are needed to proceed.