First name
Middle initial
Last name
Street address
Apartment/Unit
City
State
Select one
Indiana
ZIP Code
Date of birth
Month
Day
Year
To sign up, please provide your driver's license number OR the last four digits of your Social Security number (SSN).
Driver's license number
Last four digits of your SSN
Gender
Select one
Female
Male
Other
Unspecified
Ethnicity
Select one
American Indian or Alaskan Native
Asian or Asian American
Black or African American
Native Hawaiian or other Pacific Islander
Prefer not to answer
White or Caucasian
Other
Email address
Confirm email address
How did you learn about the Indiana donor registry?
Select one
Advertisement (not including Colts mascot Blue)
Banking on Life
Bureau of Motor Vehicles
Classroom presentation
Community event or presentation
D2SL
Department of Natural Resources (DNR)
Family or Friend
Indianapolis Colts mascot Blue
News story
Other
Social media
Please send me information related to donation and transplantation, including how to purchase a Donate Life Indiana license plate.
I understand this online registration is binding and is a legal document of gift. I do solemnly swear, affirm, or certify that I am the applicant described in this application, and that the information entered herein is true and correct. By clicking the Register button I affirm that I wish to be an organ, tissue and eye donor upon my death. I would like to donate all organs and tissues for transplant, research or education. Unless under the age of 18, at the time of my death, I understand that my family cannot override my decision.*
Register
Privacy: Your status as a registered organ, tissue and eye donor will be protected as personal health information, and the security of your personal information is of the utmost importance. We will not share your registration status or personally identifiable information about you with other companies, agencies or individuals except as directly related to the donation process or as required by law. If you have questions about this policy, please contact us at 317.222.3434.