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:

NEXT OF KIN:

ADDRESS LINE 1:
ADDRESS LINE 2:
CITY:
STATE:
ZIP:

TELEPHONE DAY: ( ) -

TELEPHONE EVENING: ( ) -

DONOR'S DATE OF BIRTH: / /

SEX:
MALE
FEMALE

RACE:

IF THE DONOR IS DIAGNOSED WITH A DISORDER, NAME THE DISORDER:

DIAGNOSED WHEN AND BY WHOM?BRIEF MEDICAL/FAMILY HISTORY:

IF YOU, (THE DONOR) ARE NOT AFFLICTED WITH A DISORDER, ARE YOU THE PARENT/RELATIVE OF SOMEONE WHO IS?
NO
YES*

IF YES, DESCRIBE DISORDER AND RELATIONSHIP

SIGNATURE OF DONOR OR LEGAL GUARDIAN:

_____________________________

DATE: / /

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