Surrogate Application Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Date of Birth*Age*Height (ft)*Weight (lbs)*Are you a Canadian citizen?*YesNoAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Is it okay to leave messages related to surrogacy on your answering machine?*YesNoEmail* 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 Date Format: MM slash DD slash YYYY Would you like to have more children?*YesNoAre you religious?*YesNoIf yes, please specify:Are you adopted?*YesNoDo you have a car and insurance?*YesNoHow did you hear about Canadian Surrogacy Community?*What is your occupation?*Your employerFor 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?*YesNoIf yes, what was the outcome?Have you ever applied to adopt or foster a child?*YesNoIf 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 graduateTrade schoolCollege graduateUniversity graduateHave you ever been a surrogate before?*YesNoHave you ever donated eggs before?*YesNoIf 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 FactorPositiveNegativeDo you have any allergies? Please specify.Do you have menstrual periods every month?*YesNoHow long is your monthly cycle? (number of days between periods)*How long does your period last? (days)*Do you sometimes bleed between periods?*YesNoHow 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?*YesNoIf 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?*YesNoHave you ever been diagnosed with an emotional condition or illness?*YesNoHave you ever attempted suicide?*YesNoHave you ever had suicidal thoughts?*YesNoHave you ever been treated by a mental health professional?*YesNoDo you smoke?*YesNoDoes any member of your household smoke?*YesNoHave you ever smoked?*YesNoDo you drink alcohol?*YesNoDo you use illegal or recreational drugs?*YesNoHave you ever used illegal or recreational drugs?*YesNoHave you ever abused or had a problem with alcohol or drugs in the past?*YesNoNumber 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?*YesNoIf 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?YesNoHow 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?YesNoIf 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?*YesNoWould you be willing to selectively reduce in the event of high order multiples?*YesNoI will not selectively reduce under any circumstances*YesNoI will only selectively reduce if my health and/or the health of the pregnancy is at risk (if recommended by the obstetrician).*YesNoI am willing to reduce from twins to one at the parents’ request.*YesNoI am willing to reduce from high order multiples (3+) to twins at the parents’ request.*YesNoI am willing to reduce from high order multiples (3+) to one at the parents’ request.*YesNoI am willing to reduce from high order multiples (3+) to twins at the parents’ request.*YesNoI will not reduce from high order multiples (3+) to one at the parents’ request.*YesNoWould you allow the intended parents to attend doctor’s appointments with you?*YesNoWould you be willing to have an amniocentesis and other diagnostic testing to check for birth defects or other problems with the fetus?*YesNoIf 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?*YesNoAre 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?*YesNoIf the parents requested, would you be willing to pump, freeze and ship your breast milk for the baby?*YesNoWould 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?*Unsure0 to 6 Months6 to 12 Months12 to 18 Months18 Months or GreaterWhy 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?
