Form

Contact Info:
Name:*
E-mail:*
Full Address:*
Phone*
Cell Phone:
Work Phone:
Where did you hear about RM?

Search Engine Surrogate Mothers Online Site EDSPA.ORG American Bar Association Clinic Referrral OB/GYN Referral Attorney Referral Referred by Friend Newspaper Magazine Radio Television Myspace Facebook Ladies Who Launch
Myspace/Facebook:
Donation Questions
Application Type:
Which type of arrangement are you interested in?

Anonymous Donation Open Donation Both Unsure
Have you ever been an egg donor before?
If yes, please describe your experience and the result:
How much compensation do you think is fair and reasonable for a donor of your type, experience, and background?
Donor Health History
What is your current height?
What is your current weight?
Have you had your tubes tied?

Yes No
What is your current method of birth control?
When were you last tested for HIV? Result?
When were you last tested for other STDs? Results?
Please describe and give dates for any surgeries or major illnesses:
For each of your children list the following: name, year of birth, birth weight, gesational age at delivery, and delivery method:
Have you ever had any abortions, miscarriages, or still births? Please give appx dates:
Have you ever received fertility treatments in order to become pregnant?

Yes No
Please describe any difficulies women in your family have had getting pregnant or carrying a pregnancy to term:
Please describe any pregnancy/delivery complications, illnesses, difficulties:
RH +/-

Positive Negative Unsure
Are you a carrier of cystic fibrosis?

Yes No Unsure
Family Health History
What is your mother's current age? Please also list any illnesses she has had that you know of.
What is your Mom's mother's current age? Please also list any illnesses she has had that you know of.
What is your Mom's father's current age? Please also list any illnesses he has had that you know of.
What is your father's current age? Please also list any illnesses he has had that you know of.
What is your Dad's mother's current age? Please also list any illnesses she has had that you know of.
What is your Dad's father's current age? Please also list any illnesses he has had that you know of.
Please provide the sexes and ages of your siblings and any illnesses they have had.
Has ANYone in your family had any of the following illnesses?

Tay-Sachs Huntington\'s Disease Sickle Cell Anemia Down\'s Syndrome Developmental Disabilities Color Blindness Hemophilia Cancer Asthma Vision loss (before age 60) Hearing loss (before age 60) Spina Bifida Cleft Lip Cleft Palate Indeterminate Sex Limb Defect (at birth) Muscular Dystrophy Multiple Sclerosis Cystic Fibrosis Dwarfism Dyslexia Heart Disease Mental Illness Drug Addiction Alcohol Abuse Kidney Disease Hydrocephaly Absent Kidney (at birth) Tuberous Sclerosis Other birth defect
If you checked any of the illnesses above, please list the illness and which relative it affected.
Donor Details
Date of Birth
Month Day Year
Have you given birth to at least one healthy child or donated eggs in the past?

Yes No
Are you currently receiving any of the following? Check all that apply:

Food Stamps Cash Assistance Medicaid for Self Medicaid for Children Not receiving public assistance
Are you taking antidepressants?

Yes No Not in the last 12 months
Do you smoke or use any tobacco products?

Yes No Not in the last 12 months
Do you drink alcoholic beverages?

Yes No Not when pregnant
Donor\'s Physical Appearance
Eye Color:
Hair Color:
Current Height:
Current Weight:
Hair Type:

Curly Wavy Straight Thin Thick Feathery Heavy Silky Coarse
Skin Tone/Type:

Fair Medium Med-Dark Dark African American Olive Reddish Golden Burns Easily Burns and Tans Does not Burn Does not Tan Heavy Freckles Light Freckles No Freckles
Frame/Bone Size:

Small Small-Medium Medium Medium-Large Large
List as much of your ethnic background as possible.
Bust, waist, and hip measurements:
Did you ever wear braces or other orthodontic appliance on your teeth?
What is your best physical feature?
Donor Personality Questions
Hobbies:
What are your favorite books and/or writers?
Which celebrity most reminds you of yourself (not based on appearance)?
What were your favorite/best subjects in school?
Do you play a musical instrument and have you had any accomplishments with the talent?
Do you have any special talents, especially ones for which you have been publicaly recognized or rewarded?
Do you play any sports, especially those with which you have experienced some level of acheivement?
Please read the list of adjectives and check all that you feel DO apply to you, generally speaking:

Happy Outgoing Irresponsible Resourceful Kind Apathetic Social Sarcastic Elated Spirited Miserable Stubborn Forgiving Worrisome Cynical Hateful Rigid Dramatic Talented Narcissistic Determined Devoted Ambitious Selfish Volatile Greedy Candid Shy Intelligent Politically Active Willful Earnest Rambunctious Timid Youthful Uncouth Impossible Outrageous Polished Ardent Strong Dull Confident Cocky Fragile Masculine Hard Grateful Jubilant Keen Loving Zealous Cranky Vibrant Boastful Nostalgic Malicious Funny Irritable Responsible
Is there any other acheivement, skill, or charicteristic you would like potential families to know about you?
Work & Family:
Did you graduate from high school?

Yes No GED
Did you go to college?

I never went to college I went to college and received a degree I went to college but did not finish I plan to go back and finish someday I do not intend to go to college
If you received a degree, what was the degree?
Tell us about what you do for a living:
What are your professional goals?
Are you married?

Married Single Dating In a long term relationship Living with Partner
Partner's Name:
How long have you been together?
How did your partner react to the idea of donating eggs or what do you think the reaction will be when you do tell them?
Closing Notes:
Check ALL family types you would consider:

Straight Married Gay Lesbian Single Man Single Woman Lives in my state Lives in a Neighboring State Lives on East Coast Lives on West Coast Lives in the US Lives Abroad White Black Interracial Hispanic Asian Native American Jewish Very Religious Somewhat Religious Secular All family types are okay
Is there any family type not listed above that you would be unwilling to work with?
Please use this area to write a letter to prospective parents telling them about yourself:
If you have any questions for RM staff, list them here. We will answer them during your interview.
Select a date for your intake interview using the calendar tool provided:
- Month - Day at Year / Hour Minutes
What time, on this day, should we plan to call?
Enter the phone number for us to call for this interview:
I understand that I will be required to pass a drug test before my application can be approved.*

I Agree.
I understand that I will be required to submit to a criminal background check before my application can be approved.*

I Agree.
I understand that I will be required to release certain medical records to RM staff before my application can be approved.*

I Agree
I am aware that before I can proceed with a potential match, I will be required to undergo a psychological evaluation and a physical exam conducted by the fertility clinic.*

I Agree.
I am aware that if I am living with a romantic partner, he or she will be subject to some of the same screening measures listed above.*

I Agree.
Face Photo:
Full Length Photo:
Another Photo:
Family/Children Photo:
Should be Empty:

Contact Info:

Donation Questions

Donor Health History

Family Health History

Donor Details

Donor\'s Physical Appearance

Donor Personality Questions

Work & Family:

Closing Notes: