PROSPECTIVE MOTHER

Name: ________________________________

Date of Birth: __________________________

Social Security Number: __________________

PROSPECTIVE FATHER

____________________________________

____________________________________

____________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Length of Time at that Address:    _______ years

Previous Address(es) (for last 10 years):

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Home Telephone Number: ____________________

Work Telephone Number: ____________________

Facsimile Number : ____________________

E-mail Address: ____________________

Former Name(s): ____________________

Employers: ____________________

Position: ____________________

Employer's Address

_______________________________

_______________________________

_______________________________

Length of Time with Employer: _______ years

Previous Employer(s) (for last 10 years):

_______________________________

_______________________________

_______________________________

_______________________________

Gross Monthly Income: $_________________

Other Income:

Source/Amount: ________________________

Source/Amount: ________________________

Source/Amount: ________________________

Date of Marriage: _________________________________

Place of Marriage: ________________________________

Previous Marriage(s): Yes ____ No ____

Ended by:

Death ____ Divorce ____ Date _______

Death ____ Divorce ____ Date _______

Children of Current Marriage

Children from Other Marriages or Relationships

I/we am/are interested in (check all that apply):

Assisted Reproductive Technology _____    Donor Eggs _____    Donor sperm _____

Gestational Surrogacy (Using Prospective Parents' Eggs and Sperm) _____

Surrogacy Using Surrogate's Eggs and Prospective Father's Sperm _____

Surrogacy Using Donated Eggs and Prospective Father's Sperm _____

Surrogacy Using Donated Eggs and Donated Sperm _____

Identify below any qualifications you have for egg/sperm donors, as applicable.

Race or ethnicity: ______________________________________________________________

______________________________________________________________________________

Health considerations: ___________________________________________________________

______________________________________________________________________________

Physical characteristics (including eye color, hair color, skin tone, height, weight, etc.):

______________________________________________________________________________

______________________________________________________________________________

Mental or emotional requirements: _________________________________________________

______________________________________________________________________________

Age: _________________________________________________________________________

Location: _____________________________________________________________________

Degree of involvement you wish to have in the pregnancy:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____ Wish to attend prenatal care appointments

_____ Would like surrogate to live in our home during some or all of pregnancy

_____ Want to be present at the birth

I/we have the following amount available to fund the procedure/surrogacy (may affect options that can be pursued):

Up to $1,000 _____   $1,000 to $5,000 _____   $5,000 to $10,000 _____

$10,000 to $20,000 _____   $20,000 to $30,000 _____   Over $30,000 _____

My/our medical insurance will cover _____% of the cost of assisted reproductive technology procedures.

Do you have a completed home study?   Yes _____   No _____

Has an adoption ever been denied to you?   Yes _____   No _____

Have you ever been arrested?   Adoptive mother: _______    Adoptive father: _______

If yes, explain: _________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Are you in good health?   Adoptive mother: ________    Adoptive father: _______

Explain all current and chronic illnesses, past and future surgeries, medications you are currently taking, and other relevant health information:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Do you have a history of alcohol or drug abuse?   Adoptive mother: ________     Adoptive father: ________

List three references who have known you for at least five years. Include a family member, a co-worker, and a social friend or neighbor.

Other Important Information:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Questions to Ask My Attorney:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________