Register for a Home Kit

Fill out the form below if you would like a home kit to register to be a marrow/stem cell donor with the National Marrow Donor Program Registry.

*home registration kits are free for anyone of all or part ethnic minority descent (all or part Asian and Pacific Islander, Hispanic/Latino, African American/Black or Native American/Alaska Native)

* Please note that sending out home kits can be costly for AADP, which is a non-profit organization. Please only request for a home kit if you know for sure that you would like to register. If you need more information, please contact us through phone or e-mail before filling out the form below.


Last updated 31 May 2009 by
*) Are you all or part ethnic minority?
(Asian/Pacific Islander, Hispanic/Latino, Black/African American, Native American/Alaska Native or multi-racial)		 yes
no
1) Are you between 18-60 years old? yes
2) Have you ever had any neck, back, hip or spine problems? yes
no 		If yes, please describe in as much detail as possible:

Answering yes does not necessarily disqualify you from registering.
3) Have you ever had any personal history of Asthma, Cancer, Diabetes, Hepatitis, or Heart Problems? yes
no 		If yes, please describe in as much detail as possible:

Answering yes does not necessarily disqualify you from registering.

First Name*:
Last Name*:
Mailing Address*:
City*:
State*:
ZIP/Postal Code*:
E-mail*:
Telephone*:
Additional notes, if any:*:

*If we have further questions, we will contact you*
Thank you for your support in wanting to help save a life!

You can also FAX this form to us at:
510-568-2700
For questions, call us at 510-568-3700