Thank you for choosing to apply to Genesis Rising Surrogacy. We are grateful to begin the process of working alongside you to bring a child into your family. Please fill out all of the information below. A member of our team will be in touch soon after submitting.

First Name *

Last Name *

Phone *

Email *

Is it okay to leave detailed messages related to surrogacy on this phone? *

Yes

No

What's the best way to reach you? *

Address

Street Address

City

State

Country

Postal code

Date of birth *

Age *

Are you based in the US (domestic) or International? *

USA

International

Citizenship: *

Ethnicity: *

Are you religious? *

Yes

No

If yes, what is your religion?

What is your relationship status? *

Date of marriage or registered domestic partnership:

Occupation *

Annual Income:

Have you ever: (select any that apply) *

If you marked any of the above, please provide dates of the event(s).

Would you be willing to submit to a criminal background check? *

Yes

No

What is your reason for pursuing surrogacy? *

How long have you been trying to become a parent? *

How did you hear about Genesis Rising Surrogacy? *

Applicant 2

First Name:

Last Name:

Email:

Phone Number:

Is it okay to leave detailed messages related to surrogacy on this phone?

Yes

No

What is the best way to reach you?

Phone Call

Text

Email

Address:

Date of Birth:

Age:

Citizenship:

Ethnicity:

Are you religious?

Yes

No

If yes, what is your religion?

What is your occupation?

What is your annual income?

Would you be willing to submit to a criminal background check?

Yes

No

Reason for pursuing surrogacy:

How long have you been trying to become a parent?

General Information

Do you have children? *

Yes

No

Please provide their gender, age, and if they are biological or resulted from surrogacy or adoption:

Have you pursued surrogacy in the past? *

Yes

No

If yes, please tell us about your past experience with surrogacy. Did it result in a live birth? Please share if it was a good or bad experience, and why.

Emergency Contact Name (First & Last) *

Emergency Contact Phone Number *

Relationship to Emergency Contact *

Our estimated costs for a surrogacy journey are between $110,000-$150,000.

Are you financially prepared for the surrogacy process and fees/expenses involved in that journey? *

Yes

No

What is your estimated budget? *

Health Insurance Information

If you reside in the United States, do you have health insurance coverage? *

Yes

No

I do not reside in the United States

Medical Information

Are you currently a patient at a fertility clinic? *

Yes

No

If yes, which one? Please provide name, and phone number of clinic.

Are you participating in a "guarantee" program with your clinic? *

Name of IVF Doctor:

Name of IVF Nurse (if you know it):

What medical interventions have you tried so far? *

Do you have embryos ready for transfer? *

Yes

No

In the process of creating embryos

Have your embryos been PGT tested? *

Yes

No

Unsure

What is the grade(s) of the embryo(s) you plan to transfer?

What was the age of the woman (IP or Donor) who contributed the egg at retrieval? *

How many embryos are you planning to transfer per cycle? *

Please note that ASRM guidelines discourage transferring more than 1 embryo per cycle.

Are you pursing a dual journey? (Having two surrogates at the same time) *

Yes

No

Are you currently signed with or actively working with another surrogacy agency? *

Yes

No

When would you like to match with a surrogate? *

Matching Preferences

Are there specific characteristics or qualities you are seeking in a surrogate? *

Do you require that your surrogate is vaccinated against COVID-19? *

Yes

No

Unsure

Have you completed a "Dear Surrogate" letter or video to introduce your family? *

Yes

No

I'm not sure what this is

Often gestational surrogates like to share their surrogacy journey and experience with online support groups and on social media. She would do this in a way that respects your privacy of identity and photos.

Are you supportive of your surrogate sharing her surrogacy journey on social media? *

Yes

No

Undecided

Would you want your surrogate to undergo selective reduction if twin pregnancy? *

Yes

No

Undecided

Would you want your surrogate to undergo selective reduction with triplets(+)? *

Yes

No

Undecided

Although uncommon because of PGT testing of embryos before transfer, fetuses can have chromosomal or physical irregularities or abnormalities.

Would you request your surrogate terminate pregnancy for abnormalities? *

Yes

No

Undecided

Discussing the termination of pregnancy can feel uncomfortable, but we are using this information to appropriately match you with a surrogate who feels the same way about termination as you do.

Please give us as much information as you can about your position on termination? *

Please describe the level of involvement you want with your surrogate until birth. *

Please describe level of involvement you want with your surrogate after birth? *

Do you want your surrogate to pump breastmilk for your baby? *

Yes

No

Undecided

If yes, for how long?

Do you plan to be open with your child about their surrogacy conception/birth? *

If your child wanted to meet the surrogate in the future, how would you feel? *

*When matching with a surrogate, it is important for us to know what your "deal breakers" are and any situations where you would not feel comfortable matching with a surrogate.*

Do you have any "deal breakers" for matching with a surrogate? *

Please share matching preferences or information about your situation here: *

Legal

Are you working with an attorney who specializes in assisted reproduction? *

Yes

No

If yes, please provide the name and contact information for the attorney/law firm.

Escrow/Fund Management

Please note that Premier Surrogacy does not allow escrow to be held by an attorney or law firm representing either you as the intended parent(s) or the surrogate. A disinterested 3rd party must hold it.

Are you working with an escrow management company? *

Yes

No

If yes, provide the name of the escrow company and contact information:

Supporting Documentation

Please provide us with proof of your identity (this is for our records only and will remain confidential). Please also provide several family photos to share with prospective surrogates during the matching process. If you are having issues sending photos via this form, we will follow up and have you send them via email.

Applicant 1 Government Issued ID

Applicant 2 Government Issued ID

Images of yourself, partner, or family

By typing your name(s) below, you acknowledge that you are signing this document electronically and that your signature will be binding. You also certify that your answers are correct and complete to the best of your knowledge.

Signature Applicant 1 *

Clear

Signature Applicant 2

Clear

Payment

There is a $500.00 Application Fee due at the submission of this document. Once paid, you are a registered family with our agency and will receive priority matching with waiting surrogates who meet your matching preferences.

Application Fee *

$ 500

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