Order An Individual Kit

Home Kit Questions

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)

1) Are you all or part ethnic minority? (Asian/Pacific Islander, Hispanic/Latino, Black/African American, Native American/Alaska Native or multi-racial)	Yes No

2) Are you between 18-60 years old?	Yes

3) 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.

4) 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.
Please note that sending out home kits are a large expense for A3M, which is a non-profit organization. Please make your request for a home kit only if you are certain that you would like to register. If you need additional information or have any questions, please contact our office by phone or email before requesting a home kit.

Registration

First Name:
Last Name:
Email:
Phone Number:
Street Address:
City:
State:
Zip:
Number of Kit(s):

Leslie

Leslie "Two years after I was registered, they called me at my work. I remember thinking that if that were to be my child and someone was a match for him, I would want that person to say yes. So I knew it was the right thing to do."

Make your donations for miracle marrow matches