Intended Parents Application Form 1Contact information2Personal background3Surrogacy information Name* First Last Email Address* Address* Date of Birth* MM slash DD slash YYYY Phone*Marital or Partnership Status*ChoicesSingleMarriedPartnersSpouse/Partner Name* First Last Spouse/Partner Date of Birth* MM slash DD slash YYYY What is your race? (Check All that Apply)* Caucasian Hawaiian/Pacific Islander African American Hispanic/Latino American Indian/Alaska Native Asian What is your spouse/partner’s race? (Check All that Apply)* Caucasian Hawaiian/Pacific Islander African American Hispanic/Latino American Indian/Alaska Native Asian What is your religion?* Do you practice?*ChoicesYesNoEmployer* Present Occupation* Spouse/Partner Employer* Spouse/Partner Occupation* Have you or your spouse/partner ever* Filed bankruptcy Been turned down by an adoption agency Been past due on child support Been in a substance abuse program Have current legal cases or claims pending None of the above Please explain any and all answers to the conditions listed above*Have you ever been convicted of a crime?*ChoicesYesNoHow many children do you currently have?*Choices0123456789First Child's Age* Second Child's Age* Third Child's Age* Forth Child's Age* Fifth Child's Age* Sixth Child's Age* Seventh Child's Age* Eighth Child's Age* Ninth Child's Age* Please describe the events that led you to seek a surrogate to carry your baby*Have you ever worked with a surrogate?*ChoicesYesNoIf so, when*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What qualities do you consider to be most important when choosing to work with a surrogate?*Is there a specific location where you would like your surrogate to reside?*ChoicesYesNoIf yes, please specify the location* Will you be using*ChoicesAn egg donor (donor egg, Intended Father’s sperm)A sperm donor (donor sperm, Intended Mother’s egg)Donor embryos (egg and sperm are both donated)Your genetic embryos (Intended Mother’s egg, Intended Father’s sperm)Going to try with your genetic embryos first, and if it doesn’t work, go with a donor egg and/or sperm.Do you want your surrogate to have an amniocentesis?*ChoicesYesNoHow much contact with your surrogate would you like during the pregnancy, delivery and after the child is born?*In the event of a major birth defect, would you want your surrogate to undergo an abortion?*ChoicesYesNoWould you want your surrogate to selectively reduce if she became pregnant with multiples?*ChoicesYesNoHow many transfer attempts would you feel comfortable with in order to become pregnant?*Choices123Would you consider working with a surrogate who was: (Check All that Apply)* Single Married Lesbian A Different Race Than You Do you prefer to be matched with a first-time gestational carrier or an experienced gestational carrier? Note: All surrogates in our program have delivered at least one healthy child of their own. First time gestational carriers are usually compensated $30,000 and experienced gestational carriers who have already completed at least one surrogacy journey are usually compensated $40,000 or more.*ChoicesFirst Time SurrogateExperienced SurrogateEitherPlease use this space to tell us anything else you think will be important for us to find you a great surrogate match*Letter to your surrogate here* Δ
