First Name:
* Middle Name:
Last Name:
Are you a Rabbi?		YesNo
Birth Date:		January (1) February (2) March (3) April (4) May (5) June (6) July (7) August (8) September (9) October (10) November (11) December (12) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
* Blood Type:		-- Select -- Unknown O Positive O Negative A Positive A Negative B Positive B Negative AB Positive AB Negative
Gender:		MaleFemale
Height:		Feet  Inches
Eye Color:		-- Select -- Black Blue Blue/Green Brown Gray Hazel Green Other
Address Line 1:
* Address Line 2:
City:
State: (If not in U.S. or Canada, leave blank)		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Labrador Manitoba New Foundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
Country:		-- Select -- USA Albania Algeria Angola Anquilla Antarctica Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belgium Belize Benin Bequia Bermuda Bolivia Bosnia Brazil Brunei Bulgaria Burundi Cambodia Cameroon Canada Cayman Islands Central African Republic Chile China Columbia Congo Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Dominica Dominican Republic Ecuador Egypt El Salvador Estonia Ethiopia Fiji Finland France French Antilles French Polynesia Georgia Germany Ghana Gibraltar Great Britain Greece Guam Guantanamo Bay Guatemala Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kenya Kuwait Laos Latvia Lebanon Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Malawi Malaysia Malta Mexico Monaco Montserrat Morocco Mozambique Mustique Myanmar Namibia Nepal Netherlands Nevis New Zealand Nicaragua Nigeria North Korea Northern Ireland Norway Oman Pakistan Palm Island Panama Paraguay Peru Philippines Poland Portugal Puerto Rico Romania Russia Saudi Arabia Scotland Senegal Singapore Slovakia Slovenia South Africa South Korea Spain Sri Lanka St. Kitts St. Lucia St. Vincent Suriname Sweden Switzerland Syria Taiwan Tanzania Thailand Tobago Trinidad Tunisia Turkey Uganda Union Island United Arab Emirates Uruguay USA Vatican City Venezuela Vietnam Virgin Islands Yeman Yugoslavia Zaire Zambia Zimbabwe
Zip:
Phone:
* Email:
Emergency Contact Family Name:
Home Phone:
* Work/Mobile:
Emergency Contact Family  Name:
Home Phone:
* Work/Mobile:

2. Please read the text below, and check one of the boxes.

I agree to donate my organs for immediate transplant, not for research, provided it is done in accordance with Jewish law as dictated below:

I agree to donate my organs only after:

	irreversible cessation of breathing, which is confirmed by brain-stem death. [Medically, this allows for donation of all organs. This criterion is the position of the Chief Rabbinate of Israel.]
	irreversible cessation of heartbeat, provided that no invasive preparatory procedure is done prior to cessation of heart beat. [This option reduces the possibility of  being an organ donor and limits the number of organs that may be donated.]

Any and all preparations for transplant should begin after consultation with a family-appointed rabbi. Transplants may commence only after a medical team, who is independent of the attending physicians and who is unaware that I am a potential organ donor, determines death as I have dictated above. All medical procedures must be done with proper respect, and minimum damage, to the cadaver.

I understand that the HOD Society will share my donor information with domestic and international databases provided that my specific requests are accurately conveyed.

Please don’t forget to e-mail (to admin@hods.org) or mail a passport photo to the HOD Society as soon as possible. Picture is optional, but highly preferable.