Donate Life Rx Registration Form - Donate Life New York State

Donate Life New York State (NYS) and the NYS Pharmacy Community are uniting for Donate Life Month to increase organ, eye, and tissue donor registrations and support lifesaving programs. This April, pharmacies, universities, and professionals across NYS will participate in the Donate Life Rx campaign.

Complete the registration form below by Friday, February 27, 2026 to participate.

Donate Life Rx Campaign Registration Form

Register to participate in the Donate Life Rx Campaign. Donate Life NYS will personally contact registered participants to further discuss the campaign details, and provide resources that include educational and promotional materials to spread awareness about organ, eye, and tissue donation during April.

Company

This field is for validation purposes and should be left unchanged.

Organization Information

Organization Name(Required)

Organization Address(Required)

Street Address Address Line 2 City State ZIP Code

Organization Website(Required)

Organization Phone(Required)

Contact Person

Contact Name(Required)

First Last

Contact Position/Title(Required)

Contact Email(Required)

Contact Phone(Required)

Agreement

By submitting this registration form, you are agreeing to participate and use the tracking URL provided by Donate Life NYS. You are also consenting to Donate Life NYS using your organization’s name and activities for promotion in support of our mission to increase organ, eye, and tissue donation in NYS.

I agree to participate and use the tracking URL provided by Donate Life NYS.(Required)

I agree

I consent to Donate Life NYS using our organization's name and activities for promotion(Required)

I agree

Digital Signature(Required)

Type your name to sign