www.awgbaby.com

Sheppard Office Park - 802 Sheppard Road - Voorhees, New Jersey 08043

tel: 856-566-5590 - fax: 856-566-5596

Intended Parent using a Gestational Carrier

Demographic Information

Your First Name^*

Middle Initial

Your Last Name^*

Street Address^*

City^*

State^*

Zipcode^*

Primary Phone Number^*

Primary Phone Type^*

Alternate Phone (1) Number

Alternate Phone (1) Type

Alternate Phone (2) Number

Alternate Phone (2) Type

Primary Email Address^*

Secondary Email Address^*If you are married / partnered please indicate a secondary email address for your spouse / partner. If not married or partnered please write N/A

Date of Birth^*

Last 4-digits of SS

Gender^*

Occupation^*

Length of Employment

Employer's Name

Employer's Address

Marital Status^*

Duration of Relationship with Current Partner

Tell us about your family

Describe a typical week for you and your spouse / partner / family

Describe what a surrogacy arrangement would mean to you and your family

Have you ever been arrested^*

Were you convicted

Please explain

Are you willing to have a criminal background check done for you and your partner^*

Do you have a health condition which impairs your normal daily activity, is likely to significantly reduce your life span, or will impair your ability to care for your child^*

Please provide details

Have you participated in a psychological evaluation with respect to becoming involved in an assisted reproduction procedure^*May be required in certain states to facilitate a Gestational Carrier arrangement

Demographic Information (Partner / Spouse)

Your First Name

Middle Initial

Your Last Name

Date of Birth

Last 4-digits of SS

Gender

Occupation

Length of Employment

Employer's Name

Employer's Address

Have you ever been arrested

Were you convicted

Please explain

Do you have a health condition which impairs your normal daily activity, is likely to signifigantly reduce your life span, or will impair your ability to care for your child

Please provide details

Have you participated in a psychological evaluation with respect to becoming involved in an assisted reproduction procedureMay be required in certain states to facilitate a Gestational Carrier arrangement

Demographic Information (Both Partners)

How many children do you have any children living in your home^*

Name

Date of Birth

Sex

Name

Date of Birth

Sex

Name

Date of Birth

Sex

Name

Date of Birth

Sex

Name

Date of Birth

Sex

Name

Date of Birth

Sex

Name

Date of Birth

Sex

Name

Date of Birth

Sex

Name

Date of Birth

Sex

How many embryo transfer cycles are you willing to undergo to achieve a successful pregnancy

Are you comfortable for the Gestational Carrier to carry twins or higher order multiples^*

Please provide details

Would you choose a Gestational Carrier that is NOT willing to selectively reduce or terminate for any reason^*

Under what circumstances, if any, would you want a Gestational Carrier to selectively reduce or terminate

Please indicate all candidates you would consider as a Gestational Carrier

A Married Female

A Single Female

A Woman Whose Race is Different From Your Own

A Woman Whose Religious Background is Different From Your Own

A Woman Living in a Different State

Please list the characteristics you are seeking in a Gestational Carrier

Please describe the kind of relationship you hope to establish with the gestational carrier (before, during, and after the pregnancy)

Background Fertility Information

How did you hear about our agency?

What is the cause of your infertility (if applicable)

With what clinic have you been working (if applicable)?

What type of assistance do you need?

When would you like to begin this process

Please describe the ideal qualities / attributes that you desire in a gestational carrier

Please describe the physical and genetic traits important to you in an egg donor

Using an Egg Donor

Your Characteristics

Height

Weight

Body Frame

Small

Medium

Large

Natural Hair Texture

Straight

Wavy

Curly

Race (Other)

Ethnicity (Other)

Your Partner / Spouse's Characteristics

Height

Weight

Body Frame

Small

Medium

Large

Natural Hair Texture

Straight

Wavy

Curly

Race (Other)

Ethnicity (Other)

Contact Preference

How much contact is acceptable between you and your egg donor

How far away are you willing to be from your gestational carrier and/or egg donor?

Please provide any additional comments you feel are important to this process

I certify that the information on this application is correct and may be subject to verification

I understand that by completing and sending this application electronically this serves as my signature