Donor Registration

For proper identification, please enter your name as it appears on your Indiana driver's license. If you do not have an Indiana driver's license, enter your name as it appears on your social security card or state issued ID card.

First Name*

Gender* Please select a Gender

Middle Initial*

Race/Ethnicity* Please select a race/ethnicity

Last Name*

Birthdate (MM/DD/YYYY)*

Address*

Email*

Apartment/Unit Number

Confirm Email* Email addresses must be the same

City*

Last 4 digits of Social Security number*

State*

Please send me information on a Donate Life license plate.

County* Please select a County
ZIP Code*

I understand this online registration is binding and is a legal document of gift. I do solemnly swear, affirm, or certify that I am the applicant described in this application, and that the information entered herein is true and correct. By clicking the "Register" button I affirm that I wish to be an organ, tissue and eye donor upon my death. I would like to donate all organs and tissues for transplant, research or education.* Please accept the terms