Hello, Applicants! Get started by filling in your name and email below, and press ‘next’ to scroll through the steps. Step 1 of 6 16% First Name* Last Name* Email Address* Phone* SECTION 1: MINIMUM QUALIFICATIONSPlease check all that apply* I am between the ages of 21 and 39 My BMI is under 33 I live a state other than in Arizona, Wyoming, Nebraska, Louisiana, Iowa, Mississippi, Tennessee, Indiana, Michigan, or Virginia I have a valid driver's license and reliable transportation I have car insurance I am a US citizen I have given birth before None of my children were delivered before 37 weeks I have not had more than 3 C-Sections I have not had more than 3 abortions I have not had more than 2 miscarriages I have never lost custody of a child I have never been diagnosed with Schizophrenia, Bipolar Disorder, or Post Traumatic Stress Disorder I do not suffer from frequent panic attacks Neither my partner (if applicable) nor I have ever been convicted of a felony Neither my partner (if applicable) nor I have ever been investigated by a governmental child protective agency I do not smoke or use tobacco I do not drink alcohol daily I do not use recreational drugs I am willing to take a drug test as allowed by law I am willing to make lifestyle changes such as abstaining from alcohol, caffeine, marijuana and other substances at the requests of the intended parents If my application is approved, I am willing to have my full medical records released to the agency If my application is approved, both my partner (if applicable) and I are willing to have a full background check conducted and released to the agency SECTION 2: PERSONALToday's Date MM slash DD slash YYYY List Any Other Names You've Gone By (including maiden names and nicknames) Address Street Address Address Line 2 City ZIP / Postal Code How Did You Hear About Us?Best Way To Contact You Text Call Email Date of Birth Current Age Height Weight Languages You Are Fluent In (list below)Do you have any Native American/Tribal ancestry? Yes No Primary RaceWhiteBlack or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderHispanicOtherOccupation Level of EducationSome highschoolGraduated highschoolSome collegeGraduated collegeMaster's DegreeOtherFacebook URL Instagram URL Website URL Twitter URL Date you are interested in starting a surrogacy journey Do you have any upcoming vacations planned within the next year? If yes, please explain.Do you have any upcoming moves out of State coming up in the next year? If yes, please explain.Do you have health insurance? If so, who is the provider?Are you able to travel out of State for 2-3 days? (All expenses will be paid, including childcare and lost wages.) Yes No Driver's License Number Driver's License Issuing State Social Security Number Who is your current employer? Years at current employment? Number of hours worked per week? If less than 2 years, please provide your previous occupation. SECTION 3: LIFESTYLEPlease note that many of these questions are not meant to disqualify you, but to get a better picture of what kind of person you are. Please answer as honestly as possible.Current Relationship StatusSingleIn a relationshipMarriedWidowedSeparatedDivorcedName of Spouse/Partner First Last How many years have you and your spouse/partner been together?Will your significant other support your decision to be a surrogate? Partner's Email Partner's Occupation Partner's Gender What is your main source of income? How many biological children do you have?Are you actively parenting at least one of your own children? If no, please explain.Are all of your children living with you currently? If no, please explain.Do you have legal custody of your children? If no, please explain.Have you ever considered placing a child up for adoption? If yes, please explain.Do any of your children have special needs? If yes, please explain.What is your style of discipline?Do you plan on having more children of your own? Is there anyone residing in your home other than you, your children, or your partner? Do you or your partner (if applicable) currently have any legal cases or claims pending? Have you or your partner (if applicable) ever been involved in any lawsuit? Have you ever used illegal drugs (e.g., cocaine, methamphetamines)? Have you smoked cigarettes within the last year? Do you drink alcoholic beverages? If yes, how often?Have you ever smoked or injested marijuana? If so, how much and how often?Are you exposed to any second hand smoke at home or work? (Please note that you will be tested.) Have you or your partner ever been arrested, even prior to the age of 18? (Including DUI arrests.) SECTION 4: MEDICAL/REPRODUCTIVE HISTORY(Please be honest, the questions in this application are strictly confidential and your answers will never be shown to any families that you are matched with.)Have you ever been a surrogate or egg donor before? If yes, please give details.Have you ever applied to any other programs as a surrogate or egg donor? If yes, please give details.How many babies are you willing to carry for this surrogacy journey?Check all that apply Singleton Twins Triplets What is your current method of birth control? Do you have a regular menstrual cycle? If no, please explain.Who is your current OBGYN? (Please give name, city and phone)Have you had a pap smear within the last year? Who is your current Primary Care Doctor? (Please give name, city and phone) Have you ever been clinically diagnosed with depression or bipolar disorder? Do you feel you were ever a victim of sexual, physical, or psychological abuse? Have you ever intentionally hurt or caused yourself any physical harm? Have you ever suffered from an eating disorder? Have you ever been in a substance abuse program? If yes, please explainHave you ever attempted suicide? Have you ever taken anti-depressants, anti-psychotics, or anti-anxiety medications during pregnancy? Have you ever taken ANY medication for a mental health issue? If yes, please provide details.Have you (or your partner, if applicable) ever been hospitalized for a mental health issue? Have you had any tattoos or piercings within the last year? Have you ever had a blood transfusion? Have you ever been refused as a blood donor? If yes, please explain:Do you have a history of easily bruising or bleeding? Have you been prescribed any medications in the last 5 years? If yes, please explain.Have you ever had any surgeries? If yes, please explain and give year of surgery.Have you ever been diagnosed or exposed to TB? Please check if you have ever had: Cancer Irregular heartbeat Heart problems / congenital heart defect Head injuries Thyroid problems Seizures Anemia Genital Warts Chlamydia Gonorreah Genital Herpes Syphilis HIV Hepatitis B Hepatitis C Ovarian Cysts Asthma Cystic Fibrosis Diabetes/ (Incl. Gestational) High Blood Pressure Migraine Headaches Muscular Dystrophy Neck/Back Problems PID Seizures/Fits Uterine Fibroids Asherman’s Syndrome For everything that you have said “yes” to above, please list the doctor, clinic or hospital that diagnosed you, their city and state, phone number, and the year you received the diagnosis:Have you ever had any miscarriages? If yes, how many and how far along were you?Have you ever had any abortions? If yes, how many and how far along were you?Intended Parent(s) going through this process are investing a great deal of money and emotional time with the hope of having a healthy child. Elective abortion for gender (male/female) reasons, the event of an extraordinary life change/death of the Intended Parent(s) /or a change of mind about becoming parents ARE NOT permitted for any reason. Many Intended Parent(s) have genetic testing on their embryos before the transfer. However, that is not always the case, and although the following situations occur rarely, a surrogate may be asked to abort or not to abort in accordance with the Intended Parents' decision (and with medical guidance of the IVF Physician, Obstetrician or High-Risk Specialist) if there is a risk that the child may be genetically, physically, or physiologically abnormal. That being said, if it was doctor recommended and the parents requested it, would you be able to terminate a surrogacy pregnancy?Please check all the apply. Yes No I would only be willing to terminate if my own life was at risk. It would depend on the reason (and severity) for the requested termination. Would your partner (if applicable) consider termination of a surrogacy pregnancy for the same reasons as you? If no, please explain.Do you have any past or present medical issues other than the ones mentioned above? If yes, please explain. Pregnancy #1 Date of Delivery Weeks of gestationAny complications? Number of babies delivered? Vaginal or C-Section? If C-Section please explain why.Birth Weight Has this child ever had any diagnosed medical condition? If yes, please explain.Please list the name of the delivery doctor/hospital, their city, state and phone number. Pregnancy #2 Date of Delivery Weeks of gestationAny complications? Number of babies delivered? Vaginal or C-Section? If C-Section please explain why.Birth Weight Has this child ever had any diagnosed medical condition? If yes, please explain.Please list the name of the delivery doctor/hospital, their city, state and phone number. Pregnancy #3 Date of Delivery Weeks of gestationAny complications? Number of babies delivered? Vaginal or C-Section? If C-Section please explain why.Birth Weight Has this child ever had any diagnosed medical condition? If yes, please explain.Please list the name of the delivery doctor/hospital, their city, state and phone number. Pregnancy #4 Date of Delivery Weeks of gestationAny complications? Number of babies delivered? Vaginal or C-Section? If C-Section please explain why.Birth Weight Has this child ever had any diagnosed medical condition? If yes, please explain.Please list the name of the delivery doctor/hospital, their city, state and phone number. SECTION 5: PERSONALITYPlease put a check next to the TOP 5 characteristics that best describe you. Patient Quiet Outgoing Humorous Easy-going Organized Creative Happy Healthy Athletic Intelligent Confident Self-starter Strict High energy Calm Affectionate Positive Friendly What are your career goals?Why are you interested in being a surrogate?What does your daily routine consist of?What do you do for fun?What does your support system consist of? Please name the people central to your support system.What is your favorite way to spend time with your family?How often do you exercise? Are you currently breastfeeding? If so, when do you estimate you will finish? Please describe your dietWhat is your favorite flower? What is your favorite dessert, candy or snack food? What is your biggest vice? What is your favorite movie or TV show? What is your favorite way to relax? What is your favorite type of jewelry? Please upload one to two photos of yourself. Drop files here or Select files Max. file size: 256 MB. What type of parent(s) would you work with for a surrogacy journey?Check all that apply Heterosexual couple International parents Single female parent Single male parent Same-sex couple (females) Same-sex couple (males) Emergency Contact Emergency Contact Phone Number Is there anything else you would like to mention in your application?I certify that the information contained in my application and release is true, accurate, complete and correct. I understand and agree that any misrepresentation, falsification, or material omission of information on this application may be grounds for YFA (Your Fertility Advocate) to immediately cease working with me. I understand that as a condition of my application, I will complete a background check as allowed by law. I authorize the release of my background check information, and understand that it may contain information about my background, mode of living, character, and personal reputation, as allowed by law. I also understand and agree that YFA or its clients may condition my acceptance into the surrogate program upon my passing a physical examination, psychological examination, and screening for illegal drugs as allowed by law. To the maximum extent allowed by law, I authorize the disclosure of all information about me, including but not limited to information obtained from any physician, health care professional, agency, medical practitioner, psychotherapist, dentist, health plan, hospital, clinic, laboratory, pharmacy, educational institution, law enforcement organization, governmental agency, or other covered health care provider, any insurance company and the Medical Information Bureau Inc. or other health care clearinghouse that has provided treatment or services to me or that has paid for or is seeking payment from me for such service, to YFA and its affiliated entities, representatives, employees, agents, and clients, and their agents and representatives. To the maximum extent allowed by law, I release YFA and its owners, agents, employees, officers, directors, attorneys, representatives, clients, and affiliated entities and persons from any and all liability as a result of soliciting, providing or receiving information regarding me or my character, or the use or disclosure of such information. YFA does not unlawfully discriminate in referrals or placements and no question on their application or release is used for the purpose of limiting or excluding any applicant for consideration for referral or matching placement on any basis prohibited by applicable laws or regulations. I understand and agree that the information supplied on this application has been given for the purpose of evaluating my qualifications for referral or matching placement with YFA's clients. However, I understand and agree that YFA does not guarantee my referral or matching placement with their clients. I authorize the investigation of all the information I provided in this application, unless I have indicated otherwise.CommentsThis field is for validation purposes and should be left unchanged.