SURROGATE APPLICATION

Personal information

Name (First, Middle, Last) *

Primary Race *

Date of birth *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact information

Phone *

Email *

Others

Height *

Weight *

BMI *

Occupation

Current Relationship Status

How many years have you been together?:

Name of partner/spouse(First, Middle, Last)

What is your level of education?

Do you have any religious or spiritual views?

Are you able to attend all local appointments? *

Are you actively parenting at least one of your own children? *

What is your main source of income? *

How soon would you like to begin your Surrogacy journey? *

Right away
6 months
1 year

Have you ever applied to any other agencies as a surrogate or egg donor? (if yes what agency?) *

Are there any other people residing in your home other than your children? or your partner? *

Are you able to travel out of state for 2-3 days? If travel expenses including childcare and lost wages are reimbursed? *

Do you have an existing health insurance policy? *

Background

Do you drink alcoholic beverages? *

Have you or your partner ever been investigated by governmental child protective agency? *

Do you or your partner currently have any legal cases or claims pending? *

Have you or your partner ever been involved in any lawsuit? *

Have you ever used illicit drugs (marijuana, cocaine, methamphetamines)? *

Are you exposed to any second-hand smoke at home or at work? *

Have you or your partner ever been arrested? (including DUI arrests) *

Medical/Reproductive History

Have you ever been a surrogate or egg donor before? *

Under what circumstances would you consider termination of pregnancy? (I.E. medical advisement, selective reduction, sever abnormalities?) *

How many babies are you willing to carry during this surrogacy journey? *

How many biological children do you have? *

Are all of your children living with you currently?

Do you have legal custody of your children?

Do you plan on having more children of your own?

What is your current birth control method?

Do you have a regular menstrual cycle? *

Do you have any past or current medical issues? *

Are you allergic to any medication? *

Have you ever been prescribed any medications in the last 5 years? *

Have you had any surgeries? *

Have you ever had any miscarriages? This excludes any chemical pregnancies (where the heartbeat was never detected) *

Have you had any abortions? *

Have you been vaccinated for covid-19? *

Pregnancy #1

Was this pregnancy for yourself or a surrogacy journey?

Myself
Surrogacy journey

Date of delivery

Weeks of gestation

Any complications?

Number of babies delivered?

Vaginal or C-section?

Childs Birth Weight

Pregnancy #2

Was this pregnancy for yourself or a surrogacy journey?

Myself
Surrogacy journey

Date of delivery

Weeks of gestation

Any complications?

Number of babies delivered?

Vaginal or C-section?

Childs Birth Weight

Psychological History

Have you or your partner if applicable ever had psychological counseling? *

Have you ever been prescribed any psychiatric medications? (including anti-depressants and anti-anxiety medications) *

Have you ever been hospitalized for psychiatric care? *

Have you ever attempted suicide? *

Surrogacy Questions

Base fee? *

Why do you want to become a surrogate? *

What would you like the Intended Parents know about you? *

What kind of relationship would you like with your IP's during your surrogacy journey? (friendship, very little to NO communication) *

What kind of relationship would you like after delivery? *

Would you be comfortable with the IP's in the delivery room? *

Would you be willing to pump after delivery? *

Are you comfortable having the IP in the transfer room/or recording the transfer for the IP? *

Name at least 3 people who your support system consist of? *

Are you comfortable with injections and taking oral medication for surrogacy? *

About you

Describe your personality? *

What does your daily routine consist of? *

What do you do for fun? *

What are your hobbies? *

What is your favorite way to spend time with your family? *

What is your favorite flower? *

What is your favorite way to relax? *

What is your favorite dessert, candy or snack food? *

What is your favorite color? *

What is your favorite Movie or TV show? *

Favorite type of jewelry? (I.E. rings, necklaces, or bracelets?) *

How did you hear about us? *

Can you send us a few pictures of you? *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

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I swear or affirm that the above and foregoing representations are true and correct to the best of my information, knowledge, and belief.

Sign date *