Living Donor Database

Important Details

I understand that I will not be able to contact potential living donors directly. *

I understand that if I have a profile listed on ATF's website I am required to complete a brief survey sent out by them monthly which updates them on my transplant status. If I fail to complete these, they will need to remove this page from their site. *

I understand that the American Transplant Foundation reserves the right not to publish this profile, and it can take up to a month to be published if approved. *

If you have any questions regarding this form or the Potential Living Donor Database, please email support@americantransplantfoundation.org

Patient Information

Full Name

First Name *

Last Name *

Learn more: 1+1=LIFE Mentorship Program

Are you interested in requesting a mentor through our 1+1=LIFE Mentorship Program? *

Email Address *

I would like to receive periodic emails (usually quarterly) about the American Transplant Foundation's exciting events, programs, valuable resources, news, and inspiring patient testimonials.

Mailing address: We will use this to mail personalized "business cards" with your profile information to help you with your outreach, upon request.

Primary Phone Number *

ext.

Does a potential living donor need to know your date of birth to apply to be your match? *

Date of Birth (MM/DD/YYYY)

Research Questions

I am:

Age *

Gender *

Gender Identity

Gender Identity Other

Primary Language *

Primary Language Other

Race/Ethnicity *

Race/Ethnicity Other

Transplant Information

What organ are you waiting for? *

Kidney
Liver

What is your blood type? *

What blood type does a potential living donor need to have to donate to you? *

At what transplant center are you listed? Please use complete official name. *

In what state is your transplant center located? *

If you are currently on dialysis, who is your provider?

How long have you been waiting for a transplant? *

Please Briefly describe your current medical state/transplant urgency (as if you were explaining to someone unfamiliar with medical terms. Do not include things like MELD, GFR, etc.) *

What is your life like now? *

What is the most difficult thing for you about waiting for a transplant? *

Why are you looking for a living donor? *

Do you currently have anyone being tested to become your donor? Please explain why or why not your friends/family members can donate to you. *

What efforts have you made so far to find a living donor? *

What step should a living donor take if they want to get tested for you? (online screenings, transplant center phone number, etc. Please provide any links, phone numbers, names, etc. DO NOT provide your personal contact information in this field. *

What insurance do you have? *

About You

Please share a little but about yourself (family, hobbies, lifestyle, etc.) *

What are your hopes and dreams including what you look forward to after transplant? *

What would you like to share with somebody who might consider donating an organ to you? *

Please attach 2-4 photos (high quality if possible) of yourself smiling and/or with your family if applicable (no filters or inappropriate backgrounds).

Photo 1 *

Photo 2 *

Photo 3

Photo 4

We share your story on our social media accounts. Attaching a 15-30 second video of yourself (the potential recipient) along with your application is very useful to help gain the attention of viewers. Please open this link in a new tab to view a sample "script" and instructions for recording a video. If the potential recipient is unable to record a video, a family member can speak on their behalf.

Upload your video here:

Will you be able to provide periodic updates to the American Transplant Foundation regarding your search for a donor? *

How did you hear about us? *

Explain:

Are you working with any other transplant organizations? *

What organization are you working with and how are they assisting you?

Disclaimers and Signature

PERSONAL RELEASE AGREEMENT

I hereby consent to the use of my name and likeness, for the sole purpose of promoting organ donation. I understand that the use of my name and likeness may include, but not be limited to photographs, newspaper articles, brochures, displays, television, radio, or any other public community relations material. I hereby acknowledge that this authorization is volunteered without obligation of any kind on the part of the American Transplant Foundation, its employees, and designated agents. This authorization is given without hope or expectation of reward or compensation of any kind. I hereby waive my right to inspect or approve any materials which may from time to time be created by the American Transplant Foundation and which may include my name, image, photo, likeness, or voice. I, together with my heirs, assigns, agent, guardians, and legal representatives hereby release the American Transplant Foundation from any and all claims, liabilities, and losses that may arise from its use of my name image, photo, likeness, and voice.

I agree *

AUTHORIZATION TO PUBLISH PROFILE

American Transplant Foundation Potential Living Donor Database

I authorize the American Transplant Foundation (ATF) to publish my profile on the ATF website where it will be publicly accessible to transplant candidates and others seeking information about potential living donors.

I understand that:

1. My profile will be publicly viewable online. Anyone visiting the ATF website can see my profile, including my first name (or full name and an initial if I choose), blood type, general location, personal story, and any other information I include.

2. I cannot control who sees my information. Once published online, my profile may be viewed, copied, shared, or archived by third parties. Search engines may index my profile.

3. Communications may be electronic, such as email, and such methods may not always be secure. There is no guarantee, assurance, or warranty of confidentiality.

4. I can request removal at any time by contacting ATF in writing at support@americantransplantfoundation.org but I understand that information already copied or archived by others cannot be retrieved.

5. ATF is a directory service only. ATF does not screen transplant candidates, facilitate communications, provide medical advice, or coordinate medical procedures.

6. I agree to hold ATF and its officers, directors, employees, and volunteers harmless from any claims or liabilities that may result from publishing my profile, electronic communications, or participating in its programs.

I agree and authorize ATF to publish my profile *

Signature *

Date Signed *

This program is completely free to those who need it. You can support this lifesaving initiative by joining our monthly giving program Save a Life Giving Club. Any amount makes a big impact!

Also, Follow us on social media to stay up to date on everything ATF!

Thank you for filling out this form! An ATF staff member will be in contact with you within the next few weeks with further details. We hope we can be of assistance to you on your transplant journey. Please hit "Save & close" in the top right corner to save this form.

Admin

Status Notes: add date to new items, if they found a donor: ask living or deceased, if they received a transplant: ask when

Profile Published

Link to profile

Status

In mentorship program?

Received Transplant From

Date transplanted

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