Brain Pre-Registration

Registering on behalf of Yourself or Someone Else?
Are you pre-registering on behalf of yourself or are you a parent, guardian or next of kin making arrangements on behalf of someone else?
- Self
- Someone Else
Is Donor Near Death in Next 7 - 14 Days?*
Is the donor near death within the next 7–14 days?
- No
- Yes
Please complete the remainder of this form and submit. Expect to be contacted by a representative from the BDP before the end of the next business day.
Your Information:
Your First Name*
Your Middle Name
Your Last Name*
Your Street Address*
Your Address Line 2
Your City*
Your State*
Your Zip Code*
Your Phone*
Your Alternate Phone
Your Email*
Your Relationship To Donor*
Donor Information:
Donor First Name*
Donor Middle Name
Donor Last Name*
Donor Street Address*
Donor Address Line 2
Donor City*
Donor State*
Donor Zip Code*
Donor Phone*
Donor Alternate Phone
Donor Email*
Donor Date Of Birth*
Donor Gender*
- Male
- Female
Donor race*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
Donor ethnicity*
- Hispanic or Latino
- Not Hispanic or Latino
Donor Neurological Disorder*
Has the donor ever been diagnosed with a disorder affecting the brain?
- No
- Yes
Disorder Description
Please specify the nature of the disease/disorder:
Disorder age
At what age were symptoms apparent?

What Type Of Mail*
Would you prefer to receive the registration forms by email or thru the U.S. mail?
- US Mail
- Email
Got it! Keep an eye on your mailbox for the big blue envelope from The Brain Donor Project within ten business days
Watch for an email with the subject line: “Brain Donation Registration Forms.” Check your spam folder if you don’t see the email within a few business days.
How Were You Made Aware Of The Brain Donor Project?*
- Online Search
- Patient or Disease Support Group
- Clinician or Physician
- Clinical Trial or Research Study
- Family or Friend
- Social Media
- Other
Please provide name of organization:*
Please provide name of provider or clinic:*
Please provide name of clinician or study:*
Please provide details:*
Terms & Conditions*
- I agree to the Privacy Policy
- I agree to the Terms & Conditions
- I agree to the GDPR Notice
Name
This field is for validation purposes and should be left unchanged.

Your Information: