UMMC Anatomical Gift Program Authorization Form

I, the undersigned, being 18 years of age or older, wish to donate my entire body upon my death to the University of Mississippi Medical Center (UMMC) Anatomical Gift Program for anatomical study, research, and the advancement of medical science.

I fully understand that the UMMC Anatomical Gift Program may not be able to accept my body at the time of death , in which case my next-of-kin/agent will make other arrangements for final disposition at their expense or the expense of my estate. View Criteria for Non-acceptance

Contact Information

Prefix

First name [R]

Last name [R]

Address 1 [R]

Address 2

City [R]

State [R]

Zip code [R]

Home phone

Cell phone

Email address

Vital Statistics (information will be used to complete Death Certificate)

Social Security Number [R]

Date of birth [R]

Gender assigned at birth

Birthplace

Race

Please specify any other cultural, tribal, or ethnic group(s) by which you prefer to be identified

Marital status [R]

Current spouse's name (first, middle, last) if applicable

Spouse's maiden name (if applicable)

Have you ever served in the U.S. Armed Forces?

Education (highest level completed)

Usual occupation (Type of work performed most of working life. Do not enter retired.)

Kind of business or industry

Father's name (first, middle, last) even if deceased

Mother's name (first, middle, last) even if deceased

Mother's maiden name

Agent Information

Are you an Agent signing on the Donor's behalf? [R]

If signing for Donor, what is your relationship?

Disposition of Cremains

Disposition options [R]

Return my cremains to

Relationship to donor

Mailing address 1

Mailing address 2

City

State

Zip code

Email address

Phone number

Next-of-kin/Executor of estate

Prefix

First name

Last Name

Relationship to donor

Email address

Phone number

Address 1

Address 2

City

State

Zip code

Medical History

If other, explain:

Past or current illnesses (cancer, heart, diabetes, high blood pressure, etc.)

Past or current infectious diseases (check any that apply)

MRSA

Hepatitis

HIV

Tuberculosis

Other

If other, explain:

Do you have a history of any problems with hearing or balance? (check any that apply)

Hearing loss from aging

Hearing loss due to noise

Ear trauma

Head trauma

Head or neck cancer

Vertigo or other balance disorder

Other

If other, explain:

Height (feet) [R]

Height (inches) [R]

Weight (in lbs.) [R]

Please indicate if you are willing to have your medical records donated along with your body [R]

Additional Information

Is there any other information, favorite quote, saying, or advice you would like to share with those you will be teaching?

What is your primary reason for anatomical gifting? [R]

What is your secondary reason for anatomical gifting?

If other, explain:

How did you hear about the UMMC Anatomical Gift Program?

Signature

By typing my name below, I am signing this application electronically and acknowledging that this electronic signature has the same legal force and effect as a manual signature.

Enter Your Full Legal Name [R]