Willed Body Program Instructions And Donation By Authorized Representative

Instructions For Making An Impact Beyond Life

By Legally Authorized Person

Thank you for choosing to make the gift of whole-body donation of your loved one to High Point University’s Willed Body Program. To officially make your gift you must register your decision by completing and returning the three attached forms to High Point University’s Willed Body Program. If you have any questions, you can email us at impactlife@highpoint.edu or call us at 336-841-LIFE (5433).

VITAL STATISTICS WORKSHEET

MEDICAL AND SOCIAL HISTORY WORKSHEET

The information you provide will be used by the program to complete and process the death certificate, any federal, state and local government agencies reporting, as well as, the documents required for cremation.

The information you provide will increase the educational, research and scientific value of your donation. High Point University’s Willed Body Program reserves the right to release the decedent's de-identified medical and social information to students, educators, staff and researchers for the advancement of health sciences. Personal, medical and social information will NOT be released to the public.

DOCUMENT OF GIFT The Document of Gift by Legally Authorized Person is the legal form required to make an official donation to High Point University’s Willed Body Program.

The Document of Gift must be signed by the person(s) with highest legal authority to make an anatomical gift of the decedent and two witnesses in the presence of each other or by a Notary Public.

Please print all information in a legible manner and make sure to check that everything is spelled correctly.

If you do not know the answer to a question, write “unknown”. All forms must be complete and signed where indicated. Uncompleted forms will be returned for completion.

AUTHORIZED PERSONS

N.C.G.S. § 130A-412.11 provides for the following classes of persons to donate a body for educational purposes in order of priority listed:

➊

An agent of the decedent to the extent authorized under a power of attorney for health care or other record who could have made such a donation during the deceased’s life;

➋ The spouse of the decedent; ➌ Adult children of the decedent; ➍ Parents of the decedent; ➎ Adult siblings of the decedent; ➏ Adult grandchildren of the decedent; ➐ Grandparents of the decedent; ➑ An adult who exhibited special care and concern for the decedent; ➒ The persons who were acting as the guardians of the person of the decedent at the time of death; and

➓ Any person having the authority to dispose of the decedent’s body.

PLEASE MAIL OR DELIVER COMPLETED FORMS TO: High Point University Congdon School of Health Sciences Willed Body Program-D71 One University Parkway, High Point, North Carolina 27268-0001 Fax: 336-888-6395 Email: impactlife@highpoint.edu

Thank you for your generous gift of preparing our health care professionals for the world as it is going to be.

DOCUMENT OF GIFT BY LEGALLY AUTHORIZED PERSON In the hope that others will benefit and in compliance with the Revised Uniform Anatomical Gift Act of North Carolina §130A-412.3, I hereby donate the body of ______________________________________________________________________,

(Please Print: First, Middle, Last, Suffix)

Hereinafter referred to as “Decedent” as an unrestricted anatomical gift to High Point University’s Willed Body Program located in High Point, North Carolina, for use in anatomical instruction for educational purposes, research, and medical training for the advancement of health sciences. I make this donation in conformity with N.C.G.S. § 130A-412.11. I hereby certify, warrant and represent that I have no knowledge of contrary indications by the decedent and have full legal right and authority to authorize the donation of the decedent’s remains to High Point University’s Willed Body Program.

DISPOSITION OF DECEDENT'S CREMATED REMAINS (please select ONE) Subject to N.C.G.S. § 90-210.130

Following the completion of studies, I authorize the transfer of the decedent’s remains from High Point University’s Willed Body Program to a locally operated and licensed crematory contracted by the Willed Body Program for the cremation and processing of the decedent’s remains; and to accept the decedent’s cremated remains back into their care upon completion of the cremation process. I understand that upon the acceptance of the decedent’s cremated remains from the crematory, the Willed Body Program will follow the instructions for final disposition in the manner I have designated below.  I desire the cremated remains of the decedent be returned to me at my address listed.  I desire the cremated remains of the decedent be returned to one of the following individuals listed below with priority given according to the order in which they are listed. I understand that only the individuals listed below will be allowed to receive the cremated remains of the decedent. If an individual who is not listed below would like to claim the cremated remains, a court order must be presented to High Point University ordering the Willed Body Program to release the cremated remains. Should the appointed representative(s) not be available after two years I authorize High Point University’s Willed Body Program to inter the decedent’s cremated remains in the Willed Body Program’s Memorial Garden located at High Point University, High Point, North Carolina, or scatter them at sea in the Atlantic Ocean.

A. __________________________________________________________________ __________________________________________ Name of Recipient

Relationship to Decedent

______________________________________________________________________________________________________________

Street Address

City

State Zip Code

________________________________________ ____________________________________________________________________ Phone Number

Email Address

B. __________________________________________________________________ __________________________________________ Name of Recipient

Relationship to Decedent

______________________________________________________________________________________________________________

Street Address

City

State Zip Code

________________________________________ ____________________________________________________________________ Phone Number

Email Address

 I desire that the cremated remains of the decedent be interred in the Willed Body Program's Memorial Garden located at High Point University, High Point, North Carolina.  I desire that the cremated remains of the decedent be scattered at sea in the Atlantic Ocean.

TREE OF LIFE (please select ONE)  I would like the decedent's name publicly displayed on the Tree of Life located outside the Anatomy Laboratory in Congdon Hall as written. ______________________________________________________________________________________________________________

(Please Print: First, Middle, Last, Suffix)

 I would NOT like decedent’s name publicly displayed on the Tree of Life, but instead a leaf with “anonymous” and the year of donation.

Document of Gift by Legally Authorized Person - Rev. 3/14/18 Page 1 of 2

RELEASE OF MEDICAL AND SOCIAL INFORMATION In order to increase the educational, research, and scientific value of the donation, I authorize and request any health care facility in which the decedent was a patient at any time within two years prior to death, and any physician who at any time attended the decedent within two years prior to death, to furnish to any representative of High Point University’s Willed Body Program any and all records concerning the decedent’s case history, treatment and examination which the decedent may have received. I release any such physician or health care facility from any and all responsibility or liability that may arise from this authorization; and I authorize High Point University’s Willed Body Program to release the decedent’s medical and social information in a de-identified manner, as to respect the dignity of the decedent, to students, educators, staff and researchers for the advancement of health sciences.

RELEASE OF PERSONAL INFORMATION In order to notify and file all mandatory documents related to the decedent’s death with federal, state and local agencies and to allow for the cremation of the decedent’s remains with a locally contracted crematory, I authorize all pertinent personal information given by me, or by my appointed representative, be released to any representative of High Point University’s Willed Body Program for use in the notification of death, filing of required documents of death, and the cremation of the decedent’s remains; and release any person(s) from any and all responsibility or liability that may arise from this authorization.

LEGALLY AUTHORIZED PERSON CONSENT TO DONATE GIFT Being eighteen years of age or over, of sound mind and under no duress or coercion, by signing below my signature confirms that I have thoroughly read and understand the information in An Impact Beyond Life Resource Guide and this document, and hereby release the decedent to be transferred into the care of High Point University’s Willed Body Program, High Point, North Carolina. I understand any questions that may arise can be directed to the Willed Body Program by phone at (336)-841-LIFE (5433) or by email at impactlife@highpoint.edu.

___________________________________ ____________ ____________________ _____________________________

Signature of Legally Authorized Person Date Phone Number Relationship to Donor

________________________________________________________________________________________ _____________________________ Street Address City State Zip Code Email Address

TWO WITNESSES (REQUIRED) OR NOTARIZATION BY A NOTARY PUBLIC N.C.G.S. § 130A-412.7 We, the undersigned, have witnessed the legally authorized person, who has full right and authority to donate the body of the decedent, whom is eighteen years of age or over and of sound mind and under no duress or coercion, sign this document bequeathing the decedent's body to High Point University’s Willed Body Program. “Disinterested witness” means any individual except for the following: spouse, child, parent, sibling, grandchild, grandparent, guardian, or an adult who exhibited special care and concern for the donor, or a person to whom an anatomical gift could pass under N.C.G.S. § 130A-412.13 ______________________________________________________________ _______________________________________________________________ Printed Name of First Witness

Signature of First Witness _______________________________________________________________________________________________________________________________ Street Address City State Zip Code _________________________________ __________________ ________________________________________________________________________ Phone Number Date Email Address _____________________________________________________________ ________________________________________________________________ Printed Name of Disinterested Witness

Signature of Disinterested Witness _______________________________________________________________________________________________________________________________ Street Address City State Zip Code _________________________________ __________________ ________________________________________________________________________ Phone Number Date Email Address

Please deliver completed forms to: High Point University Congdon School of Heath Sciences Willed Body Program-D71 One University Parkway, High Point, North Carolina 27268-0001

Fax: 336-888-6395 | Email: impactlife@highpoint.edu Document of Gift by Legally Authorized Person - Rev. 3/14/18 Page 2 of 2

MEDICAL AND SOCIAL HISTORY WORKSHEET _______________________________________________________________________________________________________________________________ Complete Legal Name of Decedent (Please Print: First, Middle, Last, Suffix)

Date _______________________________________________________________________________________________________________________________ Street Address City State Zip Code _______________________________________________________________________________________________________________________________ Social Security Number

Date of Birth Male/Female _______________________________________________________________________________________________________________________________ Current Height Current Weight Current Health Condition (Good, Fair, Poor)

Had the decedent ever used any of the following substances?

Substance

Used Until Death

Previously Used?

Type/Amount Frequency

How Long?

If stopped, when?

Caffeine Tobacco Alcohol Recreational Drugs Please check if the decedent had any of the following communicable diseases?  Hepatitis B or C  Creutzfeldt-Jakob Disease  MRSA  HIV/AIDS

 Tuberculosis

 Syphilis

Please check if the decedent had any of the following medical conditions?  Dementia  Rheumatoid Arthritis

 Heart Murmur

 Alzheimer’s

 Gall or Kidney Stones

 Pace Maker

 Parkinson’s

 Scoliosis

 Other____________________________

 Multiple Sclerosis

 Thoracic Outlet Syndrome

Please check if the decedent had any of the following diseases?  Heart Disease

 Emphysema

 Connective Tissue Disease

 Lung Disease

 Kidney Disease

 Other____________________________

 COPD

 Liver Disease

 Asthma

 Cirrhosis

Did the decedent have Diabetes?  Yes  No Insulin or Non-Insulin Dependent and how long?___________________________________________________________________

Medical and Social History Worksheet/LAR Rev. 3/14/18 Page of 1 of 2

Please list any serious injuries or broken bones the decedent had _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Please list any major surgeries the decedent had _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Female:  Hysterectomy  Cesarean Number of Children_______________________ Male:  Prostatectomy Had the decedent ever had an organ or tissue transplant?  Yes  No Type____________________________________________________________________________________________________ Had the decedent ever been diagnosed with cancer?  Yes  No Type of Cancer

Years

_____________________________________________________________ Decendent's Primary Care Physician

Treatments

__________________________________________

Phone Number

___________________________________________________________________________________________________________________________________ Street Address City State Zip Code

Hobbies and Interests _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Other information you would like to share _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Medical and Social History Worksheet/LAR Rev. 3/14/18 Page of 2 of 2

DECEDENT'S VITAL STATISTICS WORKSHEET This information will be used to complete the death certificate, to notify federal, state and local government agencies of the death, and for cremation. If you do not know the answer, please write “unknown” in the space provided. Please print all information in a legible manner and make sure to check that everything is spelled correctly. _______________________________________________________________________________________________________________________________ Complete Legal Name of Decedent (Please Print: First, Middle, Last, Suffix)

Date of Birth _______________________________________________________________________________________________________________________________ Name Prior to First Marriage (First, Middle Last, Suffix) _______________________________________________________________________________________________________________________________ Street Address City State Zip Code ___________________________________________________________________________ County of Residence

Is the Residence Within City Limits?  Yes  No

__________________________________ ______________________________________________________________________  Male  Female Social Security Number Place of Birth (City, State and County, or Foreign Country)

______________________________________________________________ _______________________________________________________________ Father/Parent Full Name (Last Name Prior to First Marriage) Mother/Parent Full Name (Last Name Prior to First Marriage)

Marital Status:  Married  Married but Separated  Widowed  Divorced  Never Married  Unknown _______________________________________________________________________________________________________________________________ If Married, Spouse’s Name (Including Maiden) ______________________________________________________________ _______________________________________________________________ Spouse’s Phone Number

Spouse’s Email ______________________________________________________________ _______________________________________________________________ Usual Occupation (Before Retirement)

Kind of Business or Industry

EDUCATION  8th Grade Or Less  9th–12th Grade; NO Diploma  High School Graduate Or GED Completed  Some College Credit, But NO Degree  Associate Degree (e.g., AA, AS)

 Bachelor’s Degree (e.g., BA, AB, BS)  Master’s Degree (e.g., MA, MS, MEng, MEd, MSW, MBA)  Doctorate (e.g., PhD, EdD) Or Professional Degree (e.g., MD, DDS, DVM, LLB, JD)  Unknown

MILITARY INFORMATION Military Experience:  Yes  No

Military Service Number/Serial Number: _______________________________________________

Branch:  Army  Navy  Air Force  Marine Corps  Coast Guard  Selected Service  Other ______________________ Entered Active Duty (M/D/Y): ________________________ Released From Active Duty (M/D/Y): ______________________________

RACE  Asian Indian  American Indian or Alaska Native (Name of Tribe) ________________________________  Black or African American

 Chinese  Filipino  Guamanian or Chamorro  Japanese  Korean  Native Hawaiian

 Samoan  White  Vietnamese  Other Asian (Specify)

 Other Pacific Islander (Specify)

____________________

_____________________________

_____________________________  Other (Specify)

HISPANIC ORGIN  No, Not Spanish/Hispanic/Latino  Yes, Mexican, Mexican American, Chicano  Yes, Puerto Rican  Yes, Cuban

 Yes, Other Spanish/Hispanic/Latino (Please Specify) ________________________________________________________  Unknown

CONTACT INFORMATION OF LEGALLY AUTHORIZED PERSON ______________________________________________________________________________________ _______________________________________ Complete Legal Name (Please Print: First, Middle, Last, Suffix) Relationship to Donor _______________________________________________________________________________________________________________________________ Street Address City State Zip Code ___________________________________________________________________ __________________________________________________________ Phone Number Email Decedent's Vital Statistics Form Rev. 3/14/18 Page 1 of 1

Congdon School of Health Sciences Department Willed Body Program-D71 One University Parkway High Point, North Carolina 27268-0001