If you are interested in becoming a surrogate or an Egg Donor simply fill out the following informational form. All information entered here is private and confidential and will not be shared with anyone without your express written consent.  Once consent is obtained this information will only be shared with intended parents and our staff. We will review your information and someone from our office will contact you with additional information and questions.    

First Name:  

Last Name:

Date of Birth: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Age:  

Street Address


City

State:   Zip Code:

Home Phone

Cell Phone

Work Phone 

Email Address:


What are you applying to be?
Egg Donor  Traditional Surrogate  Gestational Surrogate

Are you available to be matched at this time? Choose Yes No
      If not, when are you available?

Have you ever been a surrogate or egg donor? Choose Yes No
If so, when? How many times? # 1 2 3 4 5 6 7 8 9 10+ n/a

Please mark any of the following groups that you are NOT willing
to work with:

Heterosexual Couples  Heterosexual Singles
Homosexual Couples   Homosexual Singles
Other, please explain below:

Height   Weight Build  Select Slender Athelic Average Heavyset

Eye Color

Hair Color |

Hair texture

Complexion  

Race

Religious background

Ethnic background

Are you presently married or in a committed relationship Select Yes No
If so, how long?

Please list your marriages and/or long term relationships

Do you have children? Select Yes No

Please list child's name, date of birth, birth weight and length,
delivery type and any complications.

Do you have custody of your children? Choose No Yes N/A

Academic Background

What is the highest grade of education that you have completed?
Select 8 9 10 11 High School G.E.D. Some College College Grad College Degree+

Do you have any degrees? Select Yes No
If so, please specify:

What was your G.P.A.?  

What did you score on SAT?

Which university did you attend?

General Health and Family History

What is your general condition of health? 

When was your last physical?
 

When was your last pap smear?
 

What was the result?

Please list any present medical conditions or treatment:

Please list any past medical conditions or treatment:

Please list any medications you have taken in the past and
 the reason for taking medications and date they were last taken.

Please Identify and list your current method and history of birth
control use.  (Include dates of use, methods used and any
reasons for change)

Do you Smoke?  Choose Yes No   How much?   

For how long?

Do you drink alcoholic beverages?  Choose Yes No    

How much/often?   

Do you exercise?   Choose Yes No
If so, How much?
How frequently?  

If so, what type of exercise?

What is your blood type  Choose A B AB O don't know    

What is your RH factor?  Choose positive negative don't know

Family History:

Do you have any siblings?  Choose Yes No

Please list the name and ages of your siblings and indicate
where you lie in the birth order:

 

Father’s Father  Choose living deceased  
Age or Age at the date of death  
If deceased, cause of death 

Father’s Mother  Choose living deceased
Age or Age at the date of death  
If deceased, cause of death 

Mother’s Father  Choose living deceased
Age or Age at the date of death  
If deceased, cause of death 

Mother’s Mother  Choose living deceased
Age or Age at the date of death  
If deceased, cause of death 

Father  Choose living deceased
Age or Age at the date of death  
If deceased, cause of death 

Mother Choose living deceased
Age or Age at the date of death  
If deceased, cause of death 

Are you aware of any genetic or hereditary, mental, emotional or developmental problems in your family?    

  Choose Yes No

If so please describe the problem and relationship of  the person suffering from it to you (e.g. Aunt, Uncle brother cousin etc.)

Please check all of the following boxes that apply. 
In my family and among my blood relations there is a history of:

  Cancer     Diabetes     High Blood Pressure

  Tuberculosis     Stroke     Heart Trouble   

Mental Illness      Neurofibromatosis

  Alcoholism     Down Syndrome    Tay-Sachs Disease

  Sickle Cell Anemia     Cystic Fibrosis   

  Hyperactivity    Hemophilia     Huntingtons  

  Multiple Sclerosis    Lou Gehrigs Disease  Allergies
Other    Twins      Triplets

If you marked any of the above, Please explain:

Have you ever required psychological treatment?     Choose Yes No  

Were you hospitalized?     Choose Yes No

Were you medicated?       Choose Yes No

Are currently receiving ongoing care?      Choose Yes No

If you answer to any of the above, please explain in detail:

Are you at risk for contracting the AIDS Virus?    Choose Yes No Unsure
Please explain

Have you ever had a sexually transmitted disease?        Choose Yes No  

If so, please explain:

Do you have health insurance with maternity?   Choose Yes No

Name of Insurance Co.

Policy No.

Does your insurance cover surrogate pregnancies? Choose Yes No

Background Information:

Are you presently working?  Choose Yes No

What is your current employment history?

Are you currently on any type of public assistance? Choose Yes No

Have you or your spouse or partner ever been arrested?
  Choose Yes No

If so, please explain:

Have you ever filed for bankruptcy?    Choose Yes No
If so, when? 

Have you or anyone living in your home ever been investigated or convicted of child abuse, neglect or child endangerment?  Choose Yes No

If so, please explain:

Have you or anyone living in your home ever been arrested for, or convicted of, a serious crime or felony?
  Choose Yes No

If so please explain:

Have you ever placed a child for adoption?         Choose Yes No

If so, please explain the relationship that you have with
the child and the adoptive parents:

General Personal Information:

Please describe your personality:

Describe your future goals:

What are your hobbies and talents:

Please explain why you want to be a surrogate and/or egg donor:

 Do you want to have more children?   Choose No Yes

 How did you hear about Surrogacy and/or Egg donation:

What do you consider to be the most important qualities in choosing prospective parents

Would you have any problems with the prospective parents participating in the birth process:

Would you be willing to have an abortion if it was determined that the baby would be born with defects? Choose Yes No

Why or Why not:?
 

 Would you consider selective reduction if it was determined that there were:

Twins? Choose Yes No   Triplets?  Choose Yes No    

Quads? Choose Yes No     Other?  Choose Yes No

 What type of relationship would you like with the child after the birth?

What are your feeling about the child wanting to meet you someday?

As a surrogate what would you say to the intended couple to assure them that you would not change your mind about relinquishing the child?

 How do your family and friends feel about your decision to be a surrogate/egg donor?

 During the surrogacy process on who can you rely on for emotional support?

 What are you most concerned about becoming a surrogate?

 Is there anything else that you would like to tell us about yourself?

 Please e-mail or send a photograph of yourself to isolina@northamericansurrogacycenter.com