Exceptional Donors, Inc.

Pre-Screening Application
First Name:
Email:
Phone:
Natural Hair Color:
Eye Color:
Hair Type:
Skin Type:
Race:
Ethnicity:
Religious Background:
Marital Status:
Number of Children:
Do you have any genetic diseases or illnesses that run in you family: (ie., blood, heart, neurological, mental health or other like alcoholism, drug abuse, cancer)	Yes No
If YES please explain and list familiar relationship
Are you willing to travel?	Yes No
	Yes (outside state) Yes (outside country)
Have you been a donor before?	Yes No
Yes (list number of times and outcomes)
If Yes, how many times
What were the outcomes
Highest level of completed education.
If College/University or Trade School, please provide the name of the school?
How did you hear about us?

Recipients