Willed Body Program Instructions and Donation By Individual Self Resource Forms

Instructions For Making An Impact Beyond Life

By Individual Self Thank you for choosing to make the gift of whole-body donation 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 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. All questions must be completed to the best of your knowledge.

MEDICAL AND SOCIAL HISTORY WORKSHEET 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 your 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 Individual Self 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 donor 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.

DONOR CARD

Once all forms have been received, reviewed and accepted

by High Point University’s Willed Body Program, an acknowledgement of receipt along with three Donor Cards will be mailed to you.

You should keep one Donor Card for your own personal records in a purse or wallet and give the others to trusted individuals that will assist in carrying out your wish to donate to High Point University.

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

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

CHANGE OF STATISTICAL INFORMATION To report a change of address, marital status or other pertinent information, please complete this form and deliver it 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

 Donor’s Name ______________________________________________________________________________________ (Please Print: First, Middle, Last, Suffix)

 Change in Donor’s Address

Former Address

________________________________________________________________________________________________________________________ Street Address

City

State Zip Code

Current Address

________________________________________________________________________________________________________________________ Street Address

City

State Zip Code

 Change in Phone Number

Former Phone Number _________________________________________________________________________

Current Phone Number _________________________________________________________________________

 Change in Martial Status  Married  Widowed

 Divorced

 Re-married

Change in Name _____________________________________________________________________________________ (Please Print: First, Middle, Last, Suffix)

 Other _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

Change of Statistical Information Rev. 3/14/18 Page of 1 of 1

DOCUMENT OF GIFT BY INDIVIDUAL SELF In the hope that others will benefit and in compliance with the Revised Uniform Anatomical Gift Act of North Carolina § 130A-412.3, I, _______________________________________________________________________________________________,

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

being eighteen years of age or over and of sound mind and under no duress or coercion, hereby bequeath my body, at my death, 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.

DISPOSITION OF MY CREMATED REMAINS (please select ONE) Subject to N.C.G.S. § 90-210.130 Following the completion of studies, I authorize the transfer my 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 my remains; and to accept my cremated remains back into their care upon completion of the cremation process. I understand that upon the acceptance of my cremated remains from the crematory, the Willed Body Program will follow my instructions for final disposition in the manner I have designated below.  I desire that my cremated remains be returned to one of the appointed representatives 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 my cremated remains. If an individual who is not listed below would like to claim my cremated remains, a court order must be presented to High Point University ordering the Willed Body Program to release the cremated remains. All attempts will be made to follow my decision. Should my appointed representative(s) not be available after two years I authorize High Point University’s Willed Body Program to inter my 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 Donor

______________________________________________________________________________________________________________ Street Address

City

State

Zip Code

________________________________________ ____________________________________________________________________ Phone Number

Email Address

B. __________________________________________________________________ __________________________________________ Name of Recipient

Relationship to Donor

______________________________________________________________________________________________________________ Street Address

City

State

Zip Code

________________________________________ ____________________________________________________________________ Phone Number

Email Address

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

TREE OF LIFE (please select ONE)  I would like my name publicly displayed on the Tree of Life located at the entrance of the anatomy laboratory in Congdon Hall as written. ______________________________________________________________________________________________________________

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

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

Document of Gift by Individual Self - Rev. 3/14/18 Page 1of 2

RELEASE OF MEDICAL AND SOCIAL INFORMATION In order to increase the educational, research, and scientific value of my donation following my death, I authorize and request any health care facility in which I was a patient at any time within two years prior to my death, and any physician who at any time attended me within two years prior to my death, to furnish to any representative of High Point University’s Willed Body Program any and all records concerning my case history, treatment and examination which I 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 my medical and social information in a de-identified manner, as to respect the dignity of my donation, 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 my death with federal, state, and local, agencies and to allow for the cremation of my remains with a locally contracted crematory, I authorize all pertinent personal information given by me or an appointed representative, prior to my death, or by a legally authorized person after my death, be released to any representative of High Point University’s Willed Body Program for use in the notification of my death, filing of required documents of my death, and the cremation of my remains; and release any person(s) from any and all responsibility or liability that may arise from this authorization.

DONOR CONSENT TO DONATE GIFT 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 that my closest relative or legally authorized person(s) have been told of my wish to donate my body and agree at the time of my death to notify High Point University’s Willed Body Program to arrange the transfer of my body to High Point University’s Willed Body Program, located in 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 Donor

Date

Phone Number

Email Address

______________________________________________________________________________________________________________________________ Street Address

City

State Zip Code

TWO WITNESSES (REQUIRED) OR NOTARIZATION BY A NOTARY PUBLIC N.C.G.S. § 130A-412.7 We, the undersigned, have witnessed the donor, whom is eighteen years of age or over and of sound mind and under no duress or coercion, sign this document bequeathing his/her body, upon their death, 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

This form should be executed in duplicate. A copy should be kept by the donor and a copy should be delivered 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 Individual Self - Rev. 3/14/18 Page 2 of 2

MEDICAL AND SOCIAL HISTORY WORKSHEET _______________________________________________________________________________________________________________________________ Donor Name (Please Print: First, Middle, Last, Suffix)

Date _______________________________________________________________________________________________________________________________ Street Address

City

State Zip Code _______________________________________________________________________________________________________________________________ Phone Number

Date of Birth

Male/Female _______________________________________________________________________________________________________________________________ Current Height

Current Weight

Current Health Condition (Good, Fair, Poor)

Have you ever used any of the following substances?

Substance

Currently Use?

Previously Used?

Type/Amount Frequency

How Long?

If stopped, when?

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

 Tuberculosis

 Syphilis

Please check if you have or have 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 you have or have had any of the following diseases?  Heart Disease

 Emphysema

 Connective Tissue Disease

 Lung Disease

 Kidney Disease

 Other____________________________

 COPD

 Liver Disease

 Asthma

 Cirrhosis

Do you have Diabetes?  Yes  No Insulin or Non-Insulin Dependent and how long?___________________________________________________________________

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

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

Years

_____________________________________________________________ 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/IS Rev. 3/14/18 Page of 2 of 2

DONOR 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 (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

AGENT OF DONOR OR NEXT OF KIN INFORMATION ______________________________________________________________________________________ Complete Legal Name (Please Print: First, Middle, Last, Suffix)

_______________________________________ Relationship to Donor

_______________________________________________________________________________________________________________________________ Street Address

City

State Zip Code ___________________________________________________________________ __________________________________________________________ Phone Number

Email Donor 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