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Qualifications – Step 1 of 6

Qualifications

Name *

前一页

后一页

Date of Birth *//

Layout

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

What is your preferred method of contact? *

Cell Phone
Email
Text

How did you hear about our program? *

Google
Facebook
Instagram
Twitter
Referral
TikTok
Friend
Family
Doctor
I am a previous surrogate
Other ad

Please let us know who referred you： *

How soon are you ready to become a surrogate? *

Right Away
3-6 months
6+ months
Still Researching
Undecided

Residency/Citizenship Status *

US Citizen
Non-US Citizen with permanent residency or valid green card
Non-US Citizen without green card
DACA with work permit
DACA without work permit

Have you given birth to at least one child? *

Have you had a healthy full term pregnancy and delivery? *

What is your current weight in pounds? (Example: 150 lbs) *

What is your height in feet and inches? (Example: 5'5) *

What is your expected base compensation? *

Do you have a valid driver's license? *

If no, please provide details about your transportation arrangements. Do you have reliable transportation? If not, who is responsible for driving you on a regular basis? *

Are you vaccinated for COVID-19? *

If not, are you willing to be vaccinated for COVID-19? *

Medical History

What was the first day of your most recent menstrual period (LMP)? *

Are your menstrual cycles regular? (If no, please explain in detail.) *

On average, how many days does your menstrual period last? *

What is your current method of birth control? *

Hormonal
IUD
Barrier
Sterilization
Birth Control Pills
None
Other

Please specify the type of contraception you are using. *

When was your most recent Pap smear? (MM/YYYY) *

Was the result normal? *

If the result was not normal, please explain the details, including the condition, when it occurred, and any treatment or follow-up care: *

Do you have any current medical conditions? If yes, please list and briefly describe each condition. *

What is your blood type? *

Are you currently taking any medications? If so, which medications and why do you take it? *

Please indicate any current allergies you have to food, medicine etc. *

Do you or anyone in your family have a history of drug or alcohol abuse?（If yes, please explain） *

Have you ever been diagnosed with any of the following sexually transmitted infections? *

Chlamydia
Venereal warts
Herpes
HIV
Other
None

Please explain the details, including the condition, when it occurred, and any treatment or follow-up care: *

Have you ever been diagnosed with any of the following health conditions? *

Hypertension
Seizure Disorder
Cancer
Blood Clotting
Diabetes
Heart Defects
Thryoid
Autoimmune Disorder
None

Please explain the details, including the condition, when it occurred, and any treatment or follow-up care: *

Have you ever been diagnosed with any of the following mental health conditions: *

Bipolar Disorder
Anxiety
Depression
Postpartum Anxiety/Depression
Schizophrenia
Obsessive Compulsive Disorder
Attention Deficit Hyperactivity Disorder (ADHD)
Self-Harming
Other
None

Please explain the details, including the condition, when it occurred, and any treatment or follow-up care: *

Have you had any surgeries? If so, please share what kind and month/year? *

Do you have a history of intravenous drug use?（If yes, please explain） *

Has your lifestyle in any way put you at risk for AIDS/HIV? If yes, please explain when and if it was treated *

Has anyone in your family ever been diagnosed with any of the following mental health conditions: *

Nervous Breakdown
Bipolar Disorder
Depression
Anxiety
Postpartum Anxiety/Depression
Schizophrenia
Obsessive Compulsive Disorder
Attention Deficit Hyperactivity Disorder (ADHD)
Self-Harming
Other
None

Please explain the details, including the condition, when it occurred, and any treatment or follow-up care: *

Have you ever undergone psychotherapy or counseling with a mental health professional?（If yes, please explain） *

Do you currently use tobacco or cannabis products? Smoke, vape, marijuana, cigarettes, etc. *

Are you exposed to secondhand smoke in your household? *

Do you consume alcoholic beverages? If so, how often? *

How frequently do you exercise? *

What types of exercise do you do? *

Weights
Running
Walking
Swimming
Dance
Gym
Hiking
Sports
Other

Please explain the details: *

Pregnancy History

Have you ever had a miscarriage? If yes, please indicate how many and the year(s). *

Have you ever had an abortion or terminated a pregnancy?（If yes, please explain） *

How would you describe your overall experience with pregnancy? *

Did you breastfeed your own child(ren), if so, how long? *

Add a pregnancy #1 *

Add a pregnancy

Name of Child *

Sex *

Male
Female

Birth Date *//

Birth Weight *

Weeks of gestation at delivery *

Vaginal Birth or C-Section *

Vaginal Birth
C-Section

Any complications? *

Please explain the details: *

Was this a surrogate pregnancy? *

Delivery Hospital？ *

Add a pregnancy #2

Add a pregnancy

Name of Child *

Sex *

Male
Female

Birth Date *//

Birth Weight *

Weeks of gestation at delivery *

Vaginal Birth or C-Section *

Vaginal Birth
C-Section

Any complications? *

Please explain the details: *

Was this a surrogate pregnancy? *

Delivery Hospital？ *

Add a pregnancy #3

Add a pregnancy

Name of Child *

Sex *

Male
Female

Birth Date *//

Birth Weight *

Weeks of gestation at delivery *

Vaginal Birth or C-Section *

Vaginal Birth
C-Section

Any complications? *

Please explain the details: *

Was this a surrogate pregnancy? *

Delivery Hospital？ *

Add a pregnancy #4

Add a pregnancy

Name of Child *

Sex *

Male
Female

Birth Date *//

Birth Weight *

Weeks of gestation at delivery *

Vaginal Birth or C-Section *

Vaginal Birth
C-Section

Any complications? *

Please explain the details: *

Was this a surrogate pregnancy? *

Delivery Hospital？ *

Add a pregnancy #5

Add a pregnancy

Name of Child *

Sex *

Male
Female

Birth Date *//

Birth Weight *

Weeks of gestation at delivery *

Vaginal Birth or C-Section *

Vaginal Birth
C-Section

Any complications? *

Please explain the details: *

Was this a surrogate pregnancy? *

Delivery Hospital? *

Have you ever experienced any complications of pregnancy: *

Pre-Eclampsia
Eclampsia
High Blood Pressure
Pre-Term Labor
Bleeding During Pregnancy
Gestational Diabetes
Postpartum Hemmorhage
Placental Issues
Intrauterine Growth Restriction
None

Please explain the details, including the condition, when it occurred, and any treatment or follow-up care: *

Would you terminate for Down’s syndrome or other chromosomal problems at your IPs’ request? *

If it was determined that the child would have severe physical or mental abnormalities (i.e. Genetic disorder, heart defect, short life expectancy) would you be willing to terminate? *

Would you be willing to pump, freeze, and ship your breast milk if your IP requested? *

Do you and your partner understand there will be times during the IVF process where you may be required to abstain from sexual activity while attempting to achieve a pregnancy for prospective parents? *

Do you want any additional children of your own? (IF ANSWER IS YES, SURROGACY COULD POSSIBLY AFFECT YOUR FERTILITY IN THE FUTURE) *

Are you willing to carry twins? *

Are you willing to carry embryos splitting to twins? *

Are you willing to reduce a twin pregnancy to singleton? *

Are there any specific situations or requests you would not be comfortable with during a surrogacy journey? *

If yes, please explain *

At the birth of the baby, are you comfortable with the IP(s) being in the delivery room? *

Are you willing to transfer untested embryos? (Embryos that have not undergone Pre-Implantation Genetic Screening- PGS, embryos that have not been genetically tested. In the past before technology advanced, PGS had not been done on the embryos and there were plenty of successful cases.) *

Are you willing to work with Intended Parents that may be HIV positive? *

Are you willing to work with Intended Parents with Hepatitis B exposure (no active infection, if medically cleared)？ *

Are you willing to work with Intended Parents with Hepatitis B exposure or immunity, provided there is no active infection and medical clearance is obtained？ *

Surrogate’s Personality, lifestyle, etc

What is your ethnic background? *

Who is your current employer? *

Please list the following details for your current job: date employment started, job duties, typical work schedule *

What is your current health insurance policy? Please include name of policy (e.g. Anthem), and source of insurance (e.g. employer) *

What is your primary spoken language? *

What levels of education have you completed? *

High School
Some College
College
Graduate

Have you ever been arrested?（If yes, please explain） *

Have you ever been involved in a Lawsuit, Civil Case, CPS case or Bankruptcy?（If yes, please explain） *

Questions about Your Relationship Status/Partner:

What is your current relationship status? *

How long has this been your current relationship status? *

What is your Partner/Spouse's full name? (First, Middle, Last)(If not applicable, please enter N/A.) *

What is your Partner’s/Spouse’s citizenship status？(If not applicable, please enter N/A.) *

What is your Partner's current occupation?(If not applicable, please enter N/A.) *

What is your Partner/Spouse's best contact number?(If not applicable, please enter N/A.) *

Has your Partner/Spouse ever been arrested? (If yes, please explain) *

Has your Spouse/Partner ever been involved in a Law Suit, Civil Case, or Bankruptcy? (If yes, please explain) *

Do you feel you can dedicate your time and commit yourself to the surrogacy process, given your current schedule and responsibilities? *

What are your hobbies/interests? *

Use three words that best describe your personality: *

Surrogacy Journey Preference

Why do you want to be a Surrogate? *

Are you able to take time off for surrogacy related appointments, be punctual, and stay in regular communication with the agency, prospective parents, and other professionals involved in the surrogacy process? *

Do you have any blackout dates when you’d be unavailable? (Vacation/Holidays) If yes, please provide the specific date or time period *

In terms of Intended Parents, you’re willing to work with, please check all that apply: *

Anyone
Domestic IPs
International IPs
Heterosexual Couple
Same Sex Couple
Single Parent (gay/lesbian)
Single Parent (Heterosexual)

Who will be your support system at home and what kind of support will they provide to you during the surrogacy? *

How do you see your ideal surrogacy journey? *

What kind of relationship would you like with your intended parents during the journey and after the journey? *

What message would you like to pass on to the prospective parents? *

ONLY FOR EXPERIENCED SURROGATES

How would you describe your prior surrogacy experience overall?

Was your surrogate pregnancy different than your other pregnancies?

Did you provide breast milk after delivery? If yes, for how long?

How was your relationship with the Intended Parents during your previous surrogacy journey?

Was your family supportive of you being a surrogate?

Was there anyone who was not supportive?

What made you want to do another journey?

What was your favorite part about being a surrogate?

Is there anything in particular you wouldn’t be okay with in your new journey?

If you were placed on bed rest, who would provide childcare and household support?

Information submission

Please send 10+ pictures of you, you and your family, you at your job, you doing your favorite hobbies, you in nature, etc. Thank you! *

Click or drag files to this area to upload. You can upload up to 10 files.

I hereby certify that all of the above information is correct and agree to submit this application. *

I accept
I do not accept

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