PowerPoint Presentation

252 Irvine Hall, Irvine, CA 92697-3950 ⁞ Phone 949-824-6061 ⁞ Fax 949-824-2114 ⁞ medschool.uci.edu/community/willed-body-program

Donor Application

Donor’s Legal Name: __________________________________

Willed Body Donors advance our mission,

Discover. Teach. Heal.

General Instructions 2

Vital Statistics 3

Health Information Worksheet 4

Donation Agreement 5-14

Order for Release 15

Last Revision: 08312021

General Instructions

UCI School of Medicine

Willed Body Program

252 Irvine Hall

Irvine, California 92697-3950

All donor registration forms must be completed and signed where indicated.

The UC Donation Agreement will require a signature witnessed by two

people or a Notary Public. Mail the completed forms, which include the

entire donor application, to the UC Irvine Willed Body Program in the

envelope provided or to the address noted above. Once the forms have

been reviewed and accepted by the Program, an acknowledgement will be

sent to you along with a donor identification card. Please feel welcome to

call the Willed Body Program at 949-824-6061 for questions or assistance

in completing the forms. All information provided will remain confidential to

the extent allowed by law.

Vital Statistics

The information provided is of great value to teaching and research and is

also required to complete certain government forms. The information will

also be used for completion and processing the death certificate with the

State of California, Office of Vital Records. All boxes must be completed to

the best of your ability. If you do not have the information for an item, write

“unknown” or “none” in that space. Do not leave any blank boxes. Please

PRINT all information and double check for spelling errors.

Worksheet for Education and Race/Ethnicity

This form is a guide when completing certain items found on the Vital

Statistics form.

Donation Agreement

Please sign this form in front of two witnesses or a Notary Public (if you are

signing the donation agreement for yourself). If the donation is made by the

authorized agent under a valid durable power of attorney for healthcare or

directive that expressly authorizes the authorized agent to make an

anatomical gift of all or part of the principal’s body, a complete legible copy

of the durable power of attorney for health care or directive must accompany

this form.

Order for Release

Please sign where indicated. This form is used only when a signed release

is required from a hospital or other institution.

Last Revision: 08312021

Vital Statistics Worksheet

PLEASE PRINT LEGIBLY-THIS INFORMATION IS USED TO COMPLETE THE DEATH CERTIFICATE

DONOR’S LEGAL NAME ________________________________________________________________________________

PREFERRED NAME (AKA) & PRONOUN___________________________________________________________________

PHONE (_____) ____________________ EMAIL____________________________________ DATE ___________________

 MALE  FEMALE  NON-BINARY

DATE OF BIRTH __________________ STATE OF BIRTH ______________ or FOREIGN COUNTRY __________________

DONOR’S SOCIAL SECURITY #__________-_______-__________ US ARMED FORCES

 Yes,  No,  Unknown

MARITAL STATUS

 NEVER MARRIED,  MARRIED,  WIDOWED,  DIVORCED,  REGISTERED DOMESTIC PARTNER

 0-11th grade

Highest grade completed: ______

12th grade, but no diploma

 High school graduate

 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,

ME d, MSW, MBA)

 Doctorate (e.g., PhD, EdD)

 Professional degree (e.g., MD, DDS,

DVM, LLB, JD)

SPANISH/HISPANIC  No,  Yes: Mexican,  Yes: Mexican American,  Yes: Other Hispanic________________________

RACE (Up to three selections allowed)

 White

 Black

 African American

 Alaska Native

 Aleut

 Inuit

 Native American

 American Indian

 Native Hawaiian

 Guamanian

 Samoan

Other Pacific Islander

 Asian Indian

 Cambodian

 Chinese

 Filipino

 Hmong

 Japanese

 Korean

 Laotian

 Vietnamese

 Thai

 Other Asian

 Other Specify:

______________________________

USUAL OCCUPATION _____________________________________________________________________________________________

(If you are now retired or disabled, please give occupation information BEFORE retirement or disability)

KIND OF INDUSTRY OR BUSINESS _______________________________________________ YEARS IN OCCUPATION _____________

DONOR USUAL ADDRESS _________________________________________________________________________________________

STREET CITY STATE/ZIP CODE

COUNTY OF RESIDENCE _______________________________________________ No. OF YEARS IN THIS COUNTY ______________

NAME OF SURVIVING SPOUSE (enter BIRTH name) ___________________________________________________________________

First Middle Last

FULL NAME OF FATHER/PARENT___________________________________________BIRTHPLACE OF PARENT _________________

First Middle Last

FULL NAME OF MOTHER/PARENT __________________________________________BIRTHPLACE OF PARENT _________________

Use birth name, if applicable First Middle Last

Last Revision: 08312021

NAME OF PHYSICIAN_____________________________________________________PHONE No. ______________________________

HEIGHT___________________WEIGHT__________________PRESENT STATE OF HEALTH___________________________________

SURGICAL HISTORY: KNEE, HIP, SHOULDER, SPINE OR OTHER JOINT?

________________________________________________________________________________________________________________

HYSTERECTOMY?

 Yes  No PROSTATECTOMY?  Yes  No

HISTORY of SMOKING?  Yes  No; if yes, how many years? _______

DISEASE HISTORY or TREATMENT: HEPATITIS A, B OR C, HIV/AIDS, TUBERCULOSIS, OTHERS (MRSA, CREUTZFELDT-JAKOB)

________________________________________________________________________________________________________________

ADDITIONAL HEALTH INFORMATION INCLUDING ILLNESSES, OPERATIONS, ACCIDENTS:

________________________________________________________________________________________________________________

HOW DID YOU HEAR OF THE PROGRAM?

 Friend

 Program Website

 Facebook/Instagram/YouTube

 Newspaper

 UC Publication/Presentation

 Doctor’s Office/Hospital

 Advanced Directive

 Other:

__________________________

RELIGIOUS AFFILIATION (optional): _________________________________________________________________________________

Health Information Worksheet

Last Revision: 08312021

UNIVERSITY OF CALIFORNIA DONATION AGREEMENT

1. INFORMATION ON THE UC ANATOMICAL DONATION PROGRAM

The UC Anatomical Donation Program at (also known as the donated body, body donation, willed body

or anatomical materials program, but referred to as “Program” in this document) accepts donations of

human bodies for use by various institutions and individuals for education and research purposes. The

Program’s goals are:

1. Assisting the education of current and future physicians, other healthcare practitioners,

anatomists, forensic scientists and mortuary technicians.

2. Contributing to scientific research that will assist in development of procedures and/or products

with the intent of improving the human condition in biomedical and scientific contexts.

Based on the Program’s current and future policies and procedures, the Program will exclusively

determine the manner in which a donated body and any data, including images, derived from the

donation will be utilized. The Program may support others in the development of commercialized

products in a limited manner; for example, with the use of non-identifying images in text books or other

instances where the primary benefit of the use is for education and research. Section 3 of this donation

agreement provides additional information about the use of bodies donated to UC.

When this agreement has been completed and the Program has confirmed registration, the donor

will be provided with a Donor Card that contains the necessary information to contact the

Program at the time of death.

Donations will remain confidential. Once a donor’s remains have been accepted into the

Program, acknowledgement will be sent only to the person, or persons, designated by a donor in

this application. “Donor” as used in this agreement means the individual whose body or part is

the subject of the anatomical gift.

Due to the nature and variability of uses for scientific research and education, cremated remains or any

by-products of the cremation process WILL NOT be returned. By signing this agreement, you, as a

donor or a donor’s legal representative, acknowledge that remains will not be returned and specifically

waive the provisions of California Health & Safety Code Section 7151.40(b) that provides for the

return of cremated remains to certain individuals. The Program will not offer exceptions to this policy

and encourages potential donors to consider the impact of this policy on their families or communities.

Initials___________________

Last Revision: 08312021

2. INSTRUCTIONS FOR SURVIVORS (RESPONSIBLE PARTY)

1. Upon the death of a donor, please notify the Program of the death immediately, as a delay can

result in rendering the remains unusable to the Program. Please ensure that body is not embalmed

and is otherwise unprepared.

2. Although every effort will be made to accept a donor’s body, the Program may decline a

donation at the time of death at its sole discretion. While this situation is unusual, please consider

alternative arrangements for the disposition of the body should the body be deemed unsuitable

for donation.

3. The University of California accepts donations throughout the State of California and, in special

circumstances, from neighboring states. Upon notification of a donor’s death, donors are

typically received by the campus program location that is geographically closest. However, the

university shall have the option of:

a. arranging for the body to be accepted by any University of California Anatomical

Donation Program location.

b. declining to accept the donation of the body.

4. The Program will have an original certificate of death filed with the county where death occurs,

in compliance with the Registrar of Births and Deaths. The donor’s responsible party must obtain

necessary copies of the certificate of death. The Program will provide the contact information for

the local Registrar.

5. Third-party donations (for example, donations made by an Agent named on a Durable Power of

Attorney for Health Care or the person who has control over the disposition of the decedent’s

body) may also be accepted. Individuals making third-party donations must sign the required

documentation found in this agreement specifying that they are compliant with the stated criteria.

6. Upon a donor’s death, the Program will send an acknowledgement letter to a family member or

friend (the person or persons you have designated in the fields below) or may contact that person

to verify information for the certificate of death or for other reasons. You may decline to

designate a recipient or you may designate more than one person. If you are signing on behalf of

the donor, you may designate yourself.

Name(s)_____________________________________Relationship(s)_______________

Address_________________________________________________________________

City/State/Zip code________________________________________________________

Phone number/E-mail______________________________________________________

I elect not to name a recipient: ________

Initials___________________

Last Revision: 08312021

3. USE OF DONATED BODIES

Whole body donors may be used in the following manner:

1. The program will determine medical suitability of a donated body through a process that may

include review of medical records, a medical or social history questionnaire and/or serology

testing. Testing may include obtaining a blood sample to screen for Hepatitis B, Hepatitis C,

HIV, or other communicable diseases that may render the body as medically unsuitable for

donation. Results of tests will not be disclosed to the donor’s designated survivor/responsible

party but will be reported to the California Department of Health Services if mandated by law.

2. A donated body may be chemically preserved by the Program or used in a non-embalmed state

as anatomical material.

3. A donated body may be dissected, examined, studied, and preserved for a substantial period of

time, including the possibility of permanent retention, and may be used for more than one

purpose. Parts of the body such as limbs or organs may be removed and separated from the

whole. Bodily fluids and tissues may be analyzed and destroyed.

4. A donated body and/or part of the body may be provided to educators, students, researchers or

others at University of California campuses, as well as to other educational institutions,

researchers, non-profit entities and entrepreneurial entities, such as those who develop surgical

instruments or healthcare products. When a donation is made, donors, survivors and/or

responsible parties cannot designate the uses to which the body will be put nor the persons or

entities that will use the body. The University of California reviews requests for uses and

approves them on a case by case basis according to their scientific and educational merit.

5. The Program may support the development of commercialized products in a limited manner

when the primary benefit of the use is for education and research (for example, in textbooks, or

educational software).

6. Donor data, including health data and images, derived during the registration, donation or use

may be used for education and research purposes. Data will be de-identified and stored or shared

securely.

7. The Program shall be entitled to recover all of its acquisition, preservation, storage,

transportation, disposition and related costs (both fixed and non-fixed) from the approved

researcher or educator (end-user).

8. If it is determined that, for any reason, a body cannot be used by the Program, or by any educator

or researcher approved for use of anatomic material donated to the Program, it will be cremated

or undergo a final disposition in a manner consistent with the existing California law. Personal

belongings received with a body including eyeglasses, dentures or pacemakers may be donated,

refurbished or recycled. Other items such as clothing or bedding will be discarded.

Initials__________________

Last Revision: 08312021

4. DISPOSITION OF DONATED BODIES

The following applies to the ultimate disposition of donor bodies by the Program. By signing this

Agreement, a donor or his/her responsible party authorizes the Program and its agents to dispose of the

donor by cremation or by another legal manner that may be approved at the time of death.

1. Because parts of the body may be removed during its use, these parts may be disposed of at

different times and at different locations. Upon completion of the use of the body or any part of

the body, the material may be cremated or otherwise disposed of by any means permitted under

state law in effect at the time of disposition.

2. Under certain circumstances, body parts, tissue and fluids may undergo disposition with material

from other donors, in accordance with California law.

3. Survivors/responsible parties will not be notified of the time, place or manner of the disposition

of a body or any part of a body, or of the final disposition of the remains. The cremation of some

parts of the body may not result in the creation of any remains for disposition due to the

composition of those body parts.

4. The donor or legally responsible person signing on behalf of the donor expressly waives the

provisions of California Health & Safety Code Section 7151.40(b) that provides for the return

of cremated remains. Due to the nature and variability of uses for scientific research and

education, cremated remains or any by-products of the cremation process WILL NOT be

returned.

Initials___________________

5. INFORMATION ON HOW TO REVOKE A DONATION

Donations may be revoked in accordance with the California Health and Safety Code. The process to

revoke a donation is different for a person donating his/her own body (self-donation) and for a donation

made by another (authorized person). Please read and acknowledge your understanding of how to

revoke a donation by affixing your initials.

1. Self-Donation

A donor may revoke an anatomical donation at any time prior to death. After death, this

donation cannot be revoked by survivors/responsible parties and survivors/responsible parties

cannot change any term or condition of the gift. By signing this agreement, a donor intends for

the University of California to have the exclusive right to control the use and disposition of their

body upon death.

2. Donation made by another authorized person

An authorized person, other than the decedent, who has the legal right to make a donation

according to California Health and Safety Code 7150.40, may revoke an anatomical donation

only if, before an incision is made or an invasive procedure has begun to prepare the donor, the

Program is made aware of the revocation.

Initials___________________

Last Revision: 08312021

PLEASE COMPLETE SECTION 6 IF YOU ARE SIGNING FOR YOURSELF. IF YOU ARE

SIGNING ON BEHALF OF THE DONOR, PROCEED TO SECTION 7. PLEASE NOTE THAT

ONLY THE DONOR OR AGENT WITH DURABLE POWER OF ATTORNEY FOR

HEALTHCARE MAY SIGN PRIOR TO THE DEATH OF THE DONOR.

6. PLEASE COMPLETE THIS SECTION WHEN SIGNING FOR YOURSELF.

I, ___________________, hereby donate my body upon my death to the University of California pursuant

to the terms and conditions set forth herein. I am at least 18 years of age. I adopt these descriptive and

declarative terms and conditions as my own and make them my instructions for the disposition of my body

upon my death. I have read and considered all of the information contained in this Donation Agreement.

I have initialed each section of the Agreement indicating my understanding of the information and my

desire to donate my body pursuant to this Agreement.

Signature Date

Print Name

______________________________________________________________________________

Address City/State/Zip

_______________________________________________________________________________

Phone/E-mail

TWO WITNESSES OR NOTARIZATION REQUIRED

This agreement must be either signed by two witnesses, with at least one as a “disinterested

witness”, OR may be notarized by a notary public in lieu of witnesses if you are signing this

donation agreement for yourself.

Last Revision: 08312021

1. WITNESSES

“Disinterested witness” means a witness other than the spouse, child, parent, sibling,

grandchild, grandparent, or guardian of donor, or another adult who exhibited special care and

concern for the individual.

We, the undersigned, have witnessed the signing of this document by the donor.

____________________________ ___________________________

Signature of Witness Signature of Disinterested Witness

___________________________ ____________________________

Print Name Print Name

___________________________ ____________________________

Address Address

___________________________ _____________________________

City/State/Zip City/State/Zip

2. NOTARIZATION

CERTIFICATE OF ACKNOWLEDGEMENT OF NOTARY PUBLIC

State of California

County of

On before me,

(insert name and title of the officer)

personally appeared , who proved

to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are

subscribed to the within instrument and acknowledged to me that he/she/they executed the same in

his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the

person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under penalty of perjury under the laws of the State of California that the foregoing

paragraph is true and correct.

WITNESS my hand and official seal.

Signature (Seal)

(Signature of Notary Officer)

Last Revision: 08312021

7. PLEASE COMPLETE THIS SECTION IF YOU ARE THE SPOUSE, REGISTERED

DOMESTIC PARTNER, AGENT NAMED IN THE DURABLE POWER OF ATTORNEY FOR

HEALTHCARE OR THE PERSON WHO HAS CONTROL OVER THE DISPOSITION OF

THE DECEDENT’S BODY.

I have read and fully understood the policies set forth in this document. As the legally responsible party

under this section for _________________________________________ (name of deceased) I wish to

donate his/her remains to the University of California. I accept all terms and conditions set forth in this

document and I know of no express, contrary information indicating that the decedent would not want to

donate his/her body.

____ I am the spouse of the deceased donor.

____ I am the registered domestic partner of the deceased donor.

____ I am the agent for the donor with power of attorney for health care

and I have the right and duty of disposition under Division 4.7 (commencing

with Section 4600) of the Probate Code or, I have been designated to control the donor’s

disposition in an Advance Health Care Directive. A copy of the Durable Power of Attorney for

Healthcare or Directive must be attached.

____ I am the declared claimant of the deceased donor and have completed the attached

affidavit in support of this claim.

____________________________________________________________________________________

Signature Relationship to Decedent Date

____________________________________________________________________________________

Print Name

Address City/State/Zip

Phone/E-mail

TWO WITNESSES REQUIRED

Last Revision: 08312021

This agreement must be signed by two witnesses, with at least one as a “disinterested

witness”.

1. WITNESSES

“Disinterested witness” means a witness other than the spouse, child, parent, sibling,

grandchild, grandparent, or guardian of donor, or another adult who exhibited special care and

concern for the individual.

We, the undersigned, have witnessed the signing of this document by the donor.

8. AFFIDAVIT IN SUPPORT OF CLAIM TO CONTROL DISPOSITION OF BODILY

REMAINS (Pursuant to Health and Safety Code Section 7100). PLEASE COMPLETE THIS

SECTION IF YOU ARE THE PERSON WHO HAS CONTROL OVER THE DISPOSITION OF

THE DECEDENT’S BODY.

Name of Decedent

Name of Claimant

Address of Claimant

Phone Number

Relationship to Decedent

____________________________

Signature of Witness

___________________________

Print Name

___________________________

Address

___________________________

City/State/Zip

___________________________

Signature of Disinterested Witness

____________________________

Print Name

____________________________

Address

_____________________________

City/State/Zip

Last Revision: 08312021

I claim the right to control the disposition of the Decedent’s bodily remains because: (check all that

apply)

The Decedent named me to control the disposition of his or her body in a will or other document

(attach a copy of the document).

I am the Decedent’s (circle one) child, parent, grandparent or nearest other relative. (If you are

the Decedent’s child, you must have the approval of the majority of the Decedent’s children to

arrange the disposition of the body. By signing below, you represent that you have the approval

of the majority of the Decedent’s children, or that you have made reasonable efforts to notify all

of the Decedent’s other children of your arranging the disposition of the Decedent’s body).

I am not aware of any person who objects to my arranging the disposition of the body of the Decedent.

I am not aware of any written or oral instruction by the Decedent, or any contract for funeral services by

the decedent, that give control of the disposition of the Decedent’s remains to any other person.

I am aware of and have received a copy of Health and Safety Code Section 7100 and agree to comply

with the provisions therein.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and

correct.

Signature_____________________________________ Date _________________

HEALTH AND SAFETY CODE

SECTION 7100

7100. (a) The right to control the disposition of the remains of a deceased person, the location and conditions of interment,

and arrangements for funeral goods and services to be provided, unless other directions have been given by the decedent

pursuant to Section 7100.1, vests in, and the duty of disposition and the liability for the reasonable cost of disposition of the

remains devolves upon, the following in the order named:

(1) An agent under a power of attorney for health care who has the right and duty of disposition under Division 4.7

(commencing with Section 4600) of the Probate Code, except that the agent is liable for the costs of disposition only in either

of the following cases:

(A) Where the agent makes a specific agreement to pay the costs of disposition.

(B) Where, in the absence of a specific agreement, the agent makes decisions concerning disposition that incur costs, in

which case the agent is liable only for the reasonable costs incurred as a result of the agent's decisions, to the extent that the

decedent's estate or other appropriate fund is insufficient.

(2) The competent surviving spouse.

(3) The sole surviving competent adult child of the decedent, or if there is more than one competent adult child of the

decedent, the majority of the surviving competent adult children. However, less than the majority of the surviving competent

adult children shall be vested with the rights and duties of this section if they have used reasonable efforts to notify all other

surviving competent adult children of their instructions and are not aware of any opposition to those instructions by the

majority of all surviving competent adult children.

Last Revision: 08312021

(4) The surviving competent parent or parents of the decedent. If one of the surviving competent parents is absent, the

remaining competent parent shall be vested with the rights and duties of this section after reasonable efforts have been

unsuccessful in locating the absent surviving competent parent.

(5) The sole surviving competent adult sibling of the decedent, or if there is more than one surviving competent adult

sibling of the decedent, the majority of the surviving competent adult siblings. However, less than the majority of the

surviving competent adult siblings shall be vested with the rights and duties of this section if they have used reasonable

efforts to notify all other surviving competent adult siblings of their instructions and are not aware of any opposition to those

instructions by the majority of all surviving competent adult siblings.

(6) The surviving competent adult person or persons respectively in the next degrees of kinship, or if there is more than one

surviving competent adult person of the same degree of kinship, the majority of those persons. Less than the majority of

surviving competent adult persons of the same degree of kinship shall be vested with the rights and duties of this section if

those persons have used reasonable efforts to notify all other surviving competent adult persons of the same degree of kinship

of their instructions and are not aware of any opposition to those instructions by the majority of all surviving competent adult

persons of the same degree of kinship.

(7) The public administrator when the deceased has sufficient assets.

(b) (1) If any person to whom the right of control has vested pursuant to subdivision (a) has been charged with first or

second degree murder or voluntary manslaughter in connection with the decedent's death and those charges are known to the

funeral director or cemetery authority, the right of control is relinquished and passed on to the next of kin in accordance with

subdivision (a).

(2) If the charges against the person are dropped, or if the person is acquitted of the charges, the right of control is returned

to the person.

(3) Notwithstanding this subdivision, no person who has been charged with first or second degree murder or voluntary

manslaughter in connection with the decedent's death to whom the right of control has not been returned pursuant to

paragraph (2) shall have any right to control disposition pursuant to subdivision (a) which shall be applied, to the extent the

funeral director or cemetery authority know about the charges, as if that person did not exist.

(c) A funeral director or cemetery authority shall have complete authority to control the disposition of the remains, and to

proceed under this chapter to recover usual and customary charges for the disposition, when both of the following apply:

(1) Either of the following applies:

(A) The funeral director or cemetery authority has knowledge that none of the persons described in paragraphs (1) to (6),

inclusive, of subdivision (a) exists.

(B) None of the persons described in paragraphs (1) to (6), inclusive, of subdivision (a) can be found after reasonable

inquiry, or contacted by reasonable means.

(2) The public administrator fails to assume responsibility for disposition of the remains within seven days after having

been given written notice of the facts. Written notice may be delivered by hand, U.S. mail, facsimile transmission, or

telegraph.

(d) The liability for the reasonable cost of final disposition devolves jointly and severally upon all kin of the decedent in the

same degree of kinship and upon the estate of the decedent. However, if a person accepts the gift of an entire body under

subdivision (a) of Section 7155.5, that person, subject to the terms of the gift, shall be liable for the reasonable cost of final

disposition of the decedent.

(e) This section shall be administered and construed to the end that the expressed instructions of the decedent or the person

entitled to control the disposition shall be faithfully and promptly performed.

(f) A funeral director or cemetery authority shall not be liable to any person or persons for carrying out the instructions of

the decedent or the person entitled to control the disposition.

(g) For purposes of this section, "adult" means an individual who has attained 18 years of age, "child" means a natural or

adopted child of the decedent, and "competent" means an individual who has not been declared incompetent by a court of law

or who has been declared competent by a court of law following a declaration of incompetence.

Last Revision: 08312021

_______________________ _______________________ ___________________

Donor’s Legal First Name Middle Last

I certify that pursuant to Section 7100, Health & Safety Code, State of California, it is my legal

right to select a disposition service. Therefore, please release the body of the above deceased

to the custody of the UCI School of Medicine Willed Body Program.

Donor OR Agent with DPOA for HealthCare Must Sign:

Please sign where indicated. This form is used only when a signed release

is required from a hospital or other institution to obtain custody of the body.

Signature:______________________________ Relationship:____________________________

(Write Donor or Agent)

Print Full Name:________________________________________________________________

Address:______________________________________________ City:_____________________

State:________________ Zip:___________________ Phone:_____________________________

Order for Release

252 Irvine Hall, Irvine, CA 92697-3950 ⁞ Phone 949-824-6061 ⁞ Fax 949-824-2114 ⁞ som.uci.edu/willedbody