Donor Registration Form
Your Details
Name
Your answer
Gender
Address
Your answer
Pincode
Your answer
Phone
Your answer
Mobile
Your answer
Email
Your answer
Date of Birth
MM
/
DD
/
YYYY
Blood Group
Your answer
Driving License Number
Your answer
Contact Details of Kin
Name
Your answer
Address
Your answer
Phone
Your answer
Mobile
Your answer
Relation
Your answer
Declaration
I wish to donate
I am aware that if I agree to release information from my submission, it will be widely available. That is, it may be placed on Shatayu website and made available in hard copy. I am also aware that the information may be further referenced in later publications. Any personal information provided, such as contact details will be disclosed to the members of Shatayu. Such information will be used or disclosed for any other purpose, without prior written consent. The Shatayu Organ Donation Register allows the rerieval of a donor's written consent on donating his/her relatives and helps them to fulfill their loved ones last wish. The donor may revoke the registration at anytime by informing Shatayu foundation of Organ Donation in wirting *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of Shatayu. Report Abuse - Terms of Service - Additional Terms