Donor's Personal Information *Legal name *Date of birth *Gender *Gender Choose not to disclose Female Male Other Transgender Female / Male-to-Female Transgender Male / Female-to-Male *Race *Race Asian / Pacific Islander Black or African American Hispanic or Latino Native American or American Indian White Other Religion Religion Buddhist Christian Hindu Jehovah Witness Jewish Muslim Sikh No religion Other Marital status Marital status Married Separated Divorced Widowed Never Married Children Children Yes No Occupation Donor's Contact Information and Preferences *Address *City *State *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Zip code Please provide at least one phone number in either the home, work or cell phone fields below: Home phone Work phone Cell phone Can we leave messages on your: Home phone? Home phone? Yes No Work phone? Work phone? Yes No Cell phone? Cell phone? Yes No *Can we communicate with you by email? *Can we communicate with you by email? Yes No *Email *Do you have a preference in how we communicate with you? *Do you have a preference in how we communicate with you? Home Phone Cell Phone Work Phone Email Postal Mail No Preference Donor's Medical History *Height *Weight *Are you taking any medications? *Are you taking any medications? Yes No List of medications Primary care physician Physician's address Physician's phone *Surgical history (if none, write N/A) *Allergies Blood type Blood type O A B AB Not Sure *Do you smoke? *Do you smoke? Yes No *Do you drink alcohol? *Do you drink alcohol? Yes No *Do you members of your family have kidney problems or diabetes? *Do any members of your family have kidney problems or diabetes? Yes No Have you ever had any of the following? Bladder infectionPancreatitis Kidney infectionKidney stones Liver disease/ HepatitisBlood disorder/ Anemia CancerBleeding problems Lung diseaseHerpes AsthmaSexually transmitted disease Heart problemsGout TuberculosisDiabetes High blood pressureStroke Drug usePsychiatric problems *Do you have a recipient you would like to donate to? *Do you have a recipient you would like to donate to? I do not have a recipient and want to learn about non-directed kidney donation to someone in need of a kidney transplant I have a recipient that I want to donate to Recipient's Information *Recipient's name *Your relationship to recipient (i.e. how do you know them and for how long) *If my recipient receives a kidney transplant from another living donor, I may be interested in learning about non-directed living kidney donation *If my recipient receives a kidney transplant from another living donor, I may be interested in learning about non-directed living kidney donation Yes No *Confirm Security Question below: