Team Member Information Form

About

Organ Donation

Overview

Become an Organ, Eye and Tissue Donor

Frequently Asked Questions

Get Involved

Become an Organ, Eye and Tissue Donor

Team Member Information Form

Please take a moment to fill out our team member information form below and tell us a little bit about yourself and your connection to organ, eye and tissue donation. We are excited to have you join us and look forward to hearing from you soon.

Name (required) *

First

Last

Address (required) *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email Address (required) *

Please enter your email, so we may follow up with you.

Preferred Contact Method?

Please let us know how we can contact you.

Type of Transplant Received?

Type of Organ or Tissue Received?

Please let us know what organ or tissue you received.

Date of Last Transplant//

Transplant Center

Please let us know where your transplant took place.

Are you a Donor Family?

Name of Donor / Year of Donation

Please let us know the name of your loved one.

Are you a Living Donor?

Date of Living Donation//

What type of organ did you donate?

Do you know the recipient of your donation? If so, please share your connection.

Are you interested in being a Team Supporter?

Tell us a little about your connection to organ, eye and tissue donation.

Are you a Transplant Professional?

Tell us a little bit about your professional connection to organ, eye and tissue donation.

Comment

Get Involved

Learn about Team MO-KAN

Become an Organ, Eye and Tissue, Donor

Our Mission

To raise awareness of the life-saving importance of organ, corneal and tissue donation through the lives of our donor families, living donors, and organ, eye and tissue recipients and those awaiting transplantation in the states of Kansas and Missouri. To increase the number of individuals registering to be organ, eye and tissue donors in Kansas and Missouri by participating in local and regional awareness events promoting organ, eye and tissue donation.

Contact Us

Team MO-KAN
626 NE Clubhouse Drive
Lee’s Summit, MO 64086

Phone: (816) 304-4914
info@teammokan.org