Thank you for applying to become a surrogate. Please answer the questions below. A member of our team will reach out shortly to answer any other questions you have and help you with next steps.

First Name *

Last Name *

Phone *

Email *

Address

Street Address

City

State

Country

Postal code

Date of birth

What is your current legal status in the United States? Please note that your responses are confidential and used only to verify your eligibility to participate in our surrogacy program. *

Please upload documentation verifying your legal status.

Have you or anyone living in your home ever been arrested or convicted of a crime? If yes, please explain: *

Do you currently use tobacco products? (cigarettes, e-cigarettes, etc) *

Yes

No

Do you use marijuana products that contain THC? (smoke joints, vape, edibles, etc) *

Yes

No

Are you a previous smoker? *

Yes

No

Have you been a gestational surrogate before? *

Yes

No

Have you ever been denied by a surrogacy agency before? *

Yes

No

Please tell us why you want to be a surrogate? *

Health Information

How many vaginal births have you had? *

How many C-Sections have you had? *

Please list dates of live births, as well as, how many weeks along you were at delivery: *

Have you had any miscarriages? *

Yes

No

Are you willing to terminate a pregnancy if the fetus has abnormalities and the intended parent(s) ask you to? You will never be asked to terminate a healthy pregnancy. *

Yes

No

Undecided

If undecided, please explain:

What is the approximate date of your last pap smear? *

What is your height? *

What is your weight? *

We use your height and weight to calculate your BMI (Body Mass Index). It must be under 34 to qualify.

Are you willing to administer self injectable medications? *

Yes

No

Are you vaccinated against COVID-19? *

Yes

No

Partner Information

What is your relationship status: *

If married, when and where were you married?

Partner/Spouse Name:

Partner/Spouse Phone Number:

Partner/Spouse Email:

Partner/Spouse Date of Birth

Is your spouse aware of your interest in becoming a surrogate?

Yes

No

It's Complicated

Your spouse will have to be on your contract, as well as complete a background check. Many clinics will require that your spouse/partner completes a drug screen as well.

Would you like to share any additional comments about your spouse's involvement, support, or areas of concern?

What type of birth control are you using to prevent pregnancy? *

Education and Occupation

Are you currently a student? *

Yes

No

Are You Currently Employed? *

Yes

No

Where do you work?

What is your job title?

How many hours do you work per week?

What is your hourly wage?

Are you currently receiving any form of public assistance? (food stamps, Medicaid, welfare, housing assistance, etc) *

Yes

No

Do you have health insurance?

Yes

No

Upload copy of your insurance card

Upload your latest paystub

Matching Preferences

What kind of family do you want to carry for? *

Are you able and willing to travel? *

Yes

No

Are you willing to carry twins? *

Yes

No

If no, are you willing to carry twins if they split in embryo? *

Yes

No

Are you willing to selectively reduce? *

Yes

No

Unsure

Only applicable if the embryo splits.

Do you have a valid driver's license? *

Yes

No

Upload a copy of your driver's license:

Do you have reliable transportation? *

Yes

No

Please upload three photos that will be used for your matching profile.

These should be photos you would feel comfortable using on a job application, use natural light, have no face altering filters, wear modest clothing.

Upload of a photo of yourself

Upload of photo of you and your children

Upload a photo of you and your partner (with children is fine) or someone who will be of great support to you on your journey

Upload an extra photo, if you want. We know it's hard to pick when there are so many good ones :)

Digital Signature *

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