Brain Donor Registration

Donor's Name:    
Address:              
City:                       
State:                               Zip Code:    
Telephone:                                               
Date of Birth:        
Neurological or Psychiatric Diagnosis:    Select applicable: Normal Control Schizophrenia Bipolar Disorder Alzheimer's Disease Dementia Pick's Disease Restless Leg Syndrome Other (Please specify)

Other: ________________________________

Next -of-Kin:             
Address:            
City:                     
State:                                     Zip Code:   
Telephone:                      
Date of Birth:       
Relationship to donor:   

Please complete form and mail to:        Harvard Brain Tissue Resource Center
                                                                          McLean Hospital
                                                                            115 Mill Street
                                                                        Belmont, MA 02478