Faces of the Games

To help in the planning and publicity efforts for the Games, we’d like to get to know more about you. You are not under any obligation to supply this information but your input will help us do a better job telling the story of the Games and organ and tissue donation. Please complete one form for each member of your family. We thank you for your assistance.

If possible, please e-mail two recent photos of you and/or other members of your family who will be coming to the Games to Bryan at bryanv@kidney.org. Please include your name, address and phone in the body of the e-mail. If this is not possible, feel free to mail two recent photos of you and/or other members of your family who will be coming to the Games with the same information printed on the back of each photo. Sorry, we cannot return photots. Please mail photos to: National Kidney Foundation, Attention Bryan Van Steenbergen, 30 East 33rd Street New York, NY 10016.

Full Name:

Sex:
Male
Female

Address:

City:

State:

Zip:

Phone: (day)

Phone: (eve)

E-mail:

Birthdate:

Name of donor:

Age at death:

Date of death:

Your relationship to donor:

Organ(s) donated (check all that apply):
kidneys
liver
heart
lungs
pancreas

Tissue(s) donated (check all that apply):
bone
veins
ligaments
skin
cornea
other:

Marital status: Please select single married

Yes
No

If so, please list their names and ages and star(*) any that are attending the Games:

Occupation:

Employer:

Employment Status: Please select full time part time volunteer currently unemployed/retired

Please tell us your family's personal organ donation story, including anything particularly unusual or dramatic that occurred:

Do you participate in any volunteer activities to support donor families or promote organ and tissue donation?

Yes
No

Please explain:

Have you attended other Transplant Games events? If so, which ones?

Has anyone else in your family ever needed a transplant?

Yes
No

If yes, please explain

Please describe your feelings about the Transplant Games and why you choose to participate:

Have any special friendships formed as a result of your participation in the Games or as a result of your donation experience?

Yes
No

If yes, please explain:

Have you had any contact with any of your transplant recipients?
Yes
No

If yes, please describe

If you haven’t already met your recipients, would you like to do this? Do you have any plans to meet in the future? Please explain:

Please list names of local or national newspapers, magazines, TV and/or radio shows that have featured your family's story (include direct web links if possible):

Are you interested and willing to participate in media interviews?

Yes
No

Digital Signature:
By clicking this box, you indicate all information submitted is correct and is provided to the NKF voluntarily.

Name:

E-mail:

Phone:

Zip:

Area of Interest:
Athlete Donor Family Living Donor Transplant Professional Supporter Volunteer Sponsor Advertise Exhibitor