* Select one	Add myself to the Registry
	Remove myself from the Registry
Your Full Name:
* Last Name:
* First Name:
* Middle:
* Gender:	Male     Female
* Date of Birth: (mm/dd/yyyy)	example entry: 04/01/1955
* Residential Address:
* Street Address:
* Address 2:
* City,State,Zip:	CO
Mailing Address (if different):
Address or PO Box:
Address 2:
City,State,Zip:	CO
Phone Number (with area code):
Enter phone number without dashes (ex: 3033294747)
Drivers License or CO ID#:
On your Driver's License, does a "Y" appear in the Donor field (on older licenses), or does a red heart with a "Y" appear in the lower right corner (on new licenses)?
	Yes No I don't have an ID
Any additional comments:
How did you hear about the Colorado Donor Registry?
The State of Colorado allows your registry to be activated only when we have received your signature for our files. You will be mailed a signature card that must be signed before your registration is activated.