Consent Form

The Hometown Donor Hero program honors donor heroes in your school. This program provides hope to your community by sharing the impact your donor hero’s gift of life made through organ and tissue donation.

Consent Form

Hometown Donor Hero Consent Form
Select the aspects of the Hometown Donor Hero Program that you would like Indiana Donor Network and Donate Life Indiana to complete.

Your name
Your name
First
Last
Your loved one's name
Your loved one's name
First
Last

Media Release

Release for Loved One
Your name
Your name
First
Last
Address
Address
City
State/Province
Zip/Postal
Please type full name

If signing for a loved one: I certify that I am the parent, legal guardian or next of kin of the individual named below and I give my consent without reservation to the foregoing on his or her behalf.