Intended Parent Application Become an Intended Parent 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 Spouse Email* 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* Spouse/Partner Religion* 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?*Are you open to working with a surrogate who resides outside of the Greater Philadelphia area?*ChoicesYesNoName of Your Fertility Clinic (if chosen) 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)How much contact with your surrogate would you like during the pregnancy, delivery and after the child is born?*What are your preferences regarding the COVID Vaccine*Surrogate must be already vaccinatedOpen to both vaccinated and unvaccinated surrogatesRequesting an unvaccinated surrogateDo you want your surrogate to undergo prenatal testing for fetal abnormalities?*ChoicesYesNoIn 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?*Choices123Open to Matching With: (check all that apply)* Single Married LGBTQ First Time Surrogate Experienced Surrogate Please 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*HiddenEmail Δ
