Before filling out this form, check your driver's license or ID card. If there is a "♥" or the word "donor" on the front, you are already enrolled in the organ & tissue donor registry and there is no need to submit this form unless your information has changed.

Registration Selection:
* Select one Add Myself to the Registry / Update My Record
Change My Status to Non-Registered
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:
Mailing Address (if different):
Address or PO Box:
Address 2:
City,State,Zip:
Telephone:
Phone Number:
Enter phone number with area code, without dashes
(ex: 3075771700)

Drivers License or WY ID Information:
License or ID#:

Additional Information:

Joining the Donor Registry means that you have elected to save lives by donating your organs and tissues at the time of your death. If there are specific organs and tissues you do not wish to donate, list them here (single restriction(s); no narrative):
* How did you hear about the Wyoming Donor Registry?

State law prohibits registry information from being sold or shared with any company or government agency. Organs are distributed according to national regulations.

The State of Wyoming allows your registration 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.