Please fill out the form below 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.
Registration Section:
Residential Address (Must be in New England):
Contact Information:
Last four digits of your Social Security Number (for ID verification purposes only):
If there are specific organs and tissues you do NOT wish to donate, list them here. Also, indicate here if you do not wish your donation to be used for research.
(for confirmation of your donor registration)
Please click on the "Submit Information" button below to continue with the registration process.
Your Full Name (Enter legal name as it might appear on your government issued ID):
*Last Name:
*First Name: *Select One: Middle Name: *Gender: *Date of Birth: *Street Address: Address 2: *City, State, Zip:     *Email Address: *Last four SS#:           
  * * How did you hear about the Donate Life New England Registry? Registering in memory of: