Fill the form below for Organ Donation

Full Name*

Initials* S/O,D/O,W/O

Name*

D.O.B*

Address*

Pincode*

Hereby Authorize the removal of my following organ/organs from my body after my death for therapeutic purpose.

KIDNEYS

LIVER

LUNGS

PANCREAS

HEART VALVES

HEART

EYES

INTESTINE

SKIN

BONE

EAR DRUM

ANY SUITABLE ORGANS & TISSUES

Blood group

Mobile Number*

Govt. Approved ID Type : PAN/Aadhaar Card/Passport/Driving License/Election Card

ID No.*

Email

Place

In case of emergency

Contact 1:

Mr/Ms*

Initials* S/O,D/O,W/O

Gaurdian Name*

DOB

Residing at*

Pin Code*

Mobile No*

Email

Contact 2:

Mr/Ms

Initials* S/O,D/O,W/O

Gaurdian Name

DOB

Residing at

Pin Code

Mobile No

Email

Pledge card will be issued on the basis of information provided above.

The final consent of family will be required before retrieving the organs even if the donor has filled a donar card.

Kutch Yuvak Sangh

1, First Floor, Takshashila co-op housing society, Gokuldas Madhavdas Pasta Road, Behind Chitra Cinema, Dadar (East), Mumbai, Maharashtra, 400014
Tel.: 022 - 2411 4001 / 2411 4002 | Email: mail@kutchyuvaksangh.org

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