I, (name), wish to register myself or a dependent minor as a brain and tissue donor with the Brain and Tissue Bank for Developmental Disorders at the University of Miami. This donation grants permission for the Brain and Tissue Bank to make every attempt within its means to coordinate recovery of brain and other tissues upon death of the above named donor for the expressed purpose of furthering the research of developmental disorders.
DONOR Name
Address 1
Address 2
City State Zip Code
Next of Kin
DONOR's Date of Birth Sex Male Female Race
If DONOR is diagnosed with disorder, name the disorder:
Brief Medical History:
If you, (the Donor) are not afflicted with a disorder, are you the parent/relative of someone who is?
YES NO
Describe the disorder and relationship:
Name of the person who filled the form:
Date
Completion of this registration form provides important formation needed to coordinate tissue recovery in the event of the death of the donor. After the Brain and Tissue Bank receives this registration form, you will receive a packet containing Anatomical Gift Act forms and Access to Medical Records forms and other materials.
