Living Donors Online!

1. Name of donor: Required

2. Name of organ or bone marrow recipient:

3. Relationship of recipient to donor (e.g., the recipient is the donor's son, sister, parent, cousin, or the donor and recipient are unrelated):

4. Form of donation—select from the drop-down list: Kidney Liver Lung Bone Marrow Other Required
>> If "Other," please specify what you donated:

5. Date of donation (month, day, year): January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

6. Your name: Required

7. Your email address—to contact you with any questions. Remember to include your full email address including the domain name, for example, my_email@aol.com. Your email address will not be disclosed in the hall of fame entry: Required

8. Hall of Fame entry—in the box below, enter the text you will like to have appear in the Living Donor Hall of Fame entry:
Required

9. Optional: Provide the living donor's email address if you would like Living Donors Online! to send a note on your behalf notifying them of their admission to the Living Donor Hall of Fame. Type the living donor's email address in the box, including the domain name, for example, donor_email@aol.com:

10. Optional: If you wish to include a picture of the living donor to display with the Hall of Fame entry, you can send a file of that picture with this form. You need to have the picture file on your computer. To attach the file to this form, please type in the full name of the file including the file path (for example, c:\mypictures\donor.jpg). You can use the Browse button to help you locate the file on your computer.


If these instructions about the file upload don't make sense to you and you'd like more information, send me a note by clicking here.

11. Would you like us to enter the date of donation on the LDO! Calendar of Anniversary Dates? This is a special calendar that contains the dates on which people donated so LDO visitors can celebrate the anniversaries of living donors. Required
Yes
No

Submit Your Entry

When you have completed the form, click on "Submit Entry." If you need to start again, click on "Clear Form" to erase your entries.