Surrogate Application - Canadian Surrogacy Community

Name*
First Last
Hidden
Date of Birth*
MM slash DD slash YYYY
Date of Birth*
Age*
Height (ft)*
Weight (lbs)*
Are you a Canadian citizen?*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Is it okay to leave messages related to surrogacy on your answering machine?*
- Yes
- No
Email*
Enter Email Confirm Email
What is your marital status? If married/divorced, for how long? (years)*
Spouse/Partner’s Full Name (if applicable)
Spouse/Partner’s Date of Birth
MM slash DD slash YYYY
Would you like to have more children?*
- Yes
- No
Are you religious?*
- Yes
- No
If yes, please specify:
Are you adopted?*
- Yes
- No
Do you have a car and insurance?*
- Yes
- No
How did you hear about Canadian Surrogacy Community?*
What is your occupation?*
Your employer
For how long have you worked here? (years)
What is your spouse’s/partner’s occupation?
For how long have they worked here? (years)
Have you ever placed a child for adoption?*
- Yes
- No
If yes, what was the outcome?
Have you ever applied to adopt or foster a child?*
- Yes
- No
If yes, please detail.
Have you ever (please check all that apply):*
- Been charged with child neglect or abuse
- Been in a substance abuse program
- Been arrested
- None of the above
If yes, please explain.
Has your spouse/partner ever (please check all that apply):*
- Been charged with child neglect or abuse
- Been in a substance abuse program
- Been arrested
- None of the above
If yes, please explain.
Please select your highest attained education level:*
- High school graduate
- Trade school
- College graduate
- University graduate
Have you ever been a surrogate before?*
- Yes
- No
Have you ever donated eggs before?*
- Yes
- No
If yes, please describe in further detail.
Would you be willing to help with following circumstances? (Check those you would be willing to help)*
- Select All
- A same-sex couple
- A single man
- A single woman
- A couple using an egg donor
- A couple using a sperm donor
- A couple using embryo donation
- A Jewish couple
- A couple or single person that already has children but wants more children
Do you have any medical problems? Please specify.
What is your blood type?
RH Factor
- Positive
- Negative
Do you have any allergies? Please specify.
Do you have menstrual periods every month?*
- Yes
- No
How long is your monthly cycle? (number of days between periods)*
How long does your period last? (days)*
Do you sometimes bleed between periods?*
- Yes
- No
How were your children conceived? (Naturally or otherwise)
Are you currently breastfeeding and if so, when do you plan to discontinue?
Are you currently taking any medications? If yes, please specify.*
Have you ever received fertility treatment in an effort to become pregnant?*
- Yes
- No
If any of your children are deceased, please state cause of death and the age of child at death:
Have you ever been prescribed medication for depression, anxiety, panic disorder, or another emotional or mental condition?*
- Yes
- No
Have you ever been diagnosed with an emotional condition or illness?*
- Yes
- No
Have you ever attempted suicide?*
- Yes
- No
Have you ever had suicidal thoughts?*
- Yes
- No
Have you ever been treated by a mental health professional?*
- Yes
- No
Do you smoke?*
- Yes
- No
Does any member of your household smoke?*
- Yes
- No
Have you ever smoked?*
- Yes
- No
Do you drink alcohol?*
- Yes
- No
Do you use illegal or recreational drugs?*
- Yes
- No
Have you ever used illegal or recreational drugs?*
- Yes
- No
Have you ever abused or had a problem with alcohol or drugs in the past?*
- Yes
- No
Number of Pregnancies*
Number of Miscarriages*
Number of Stillbirths*
Number of Live Births*
Number of Abortions*
Please list all of your delivery dates, whether they were vaginal or caesarian, how many weeks you delivered at, and the weight of each baby.*
Are you currently using contraception?*
- Yes
- No
If yes, state which method of contraception you are using:
If you ever experienced a reaction to contraception in the past, please state the contraception that caused the reaction and what reaction you experienced.
Do you currently have more than one sexual partner?
- Yes
- No
How many sexual partner have you had in the last 2 years?
How recently have you had an HIV test and what was the result?*
Have you ever had (or been treated for) a sexually transmitted disease?
- Yes
- No
If yes, please detail:
What attracted you to surrogacy?
Which qualities and attributes do you feel would make you an excellent surrogate mother?
Would you be willing to carry twins or high order multiples?*
- Yes
- No
Would you be willing to selectively reduce in the event of high order multiples?*
- Yes
- No
I will not selectively reduce under any circumstances*
- Yes
- No
I will only selectively reduce if my health and/or the health of the pregnancy is at risk (if recommended by the obstetrician).*
- Yes
- No
I am willing to reduce from twins to one at the parents’ request.*
- Yes
- No
I am willing to reduce from high order multiples (3+) to twins at the parents’ request.*
- Yes
- No
I am willing to reduce from high order multiples (3+) to one at the parents’ request.*
- Yes
- No
I am willing to reduce from high order multiples (3+) to twins at the parents’ request.*
- Yes
- No
I will not reduce from high order multiples (3+) to one at the parents’ request.*
- Yes
- No
Would you allow the intended parents to attend doctor’s appointments with you?*
- Yes
- No
Would you be willing to have an amniocentesis and other diagnostic testing to check for birth defects or other problems with the fetus?*
- Yes
- No
If there was a medical problem with the fetus and the intended parents wanted you to abort the pregnancy, would you be willing to honour their wishes?*
- Yes
- No
Are there any instances in which you would not be willing to abort the pregnancy? Please be specific and describe in detail.*
Would you allow the intended parents to be present during the birth?*
- Yes
- No
If the parents requested, would you be willing to pump, freeze and ship your breast milk for the baby?*
- Yes
- No
Would you like to remain in contact after the birth? If yes, please specify what kind of contact.*
Have you had previous surrogacy experience? If so, briefly describe.
Have you ever been affiliated or Matched with another surrogacy agency? Which one and when?*
As a percent (0-100%) how would you rate your readiness to pursue surrogacy?*
Do you have any questions or informational requirements in order to make the decision to become a surrogate? If so what are they?
What timeframe do you see yourself pursuing surrogacy?*
Why did you select that time frame?
What barriers or limitations do you see impeding your ability to become a surrogate?
Have you told your significant other of your intentions or interest in becoming a surrogate?

Media and Resources

Over the years, Angela has been asked many times to speak in the media about surrogacy, her company, and her experience as an advocate for women. From Podcasts, to a Today’s Parent article, to being filmed for a German Documentary, Angela has always been a part of bringing awareness to surrogacy and egg donation in Canada and showing the positive side of that gift of life. Explore her Media page to learn more about what she’s done to shine light on a very controversial topic.

M(Other) starring Angela
A poetic documentary expedition that raises socially highly relevant and forward-looking questions.

Watch M(Other)

Why choose us?

We set standards for how surrogacy and egg donation should be approached in Canada. Founder, Angela Pickering sits on an Ethics Committee with a team of professionals in the industry to ensure that the decisions made within her program are above reproach and do not compromise the integrity of her clients. The teams at CSC and Evolution Eggs are always striving to offer the best resources, guidance, and support.

Babies Born

Surrogates Matched

Egg Donors

Apply to Become a Surrogate

Media and Resources

Intended Parents

Why choose us?