Parent Application – Rocky Mountain Surrogacy – Find the Perfect Gestational Carrier or Surrogate

ALL INFORMATION ON THIS APPLICATION WILL BE KEPT CONFIDENTIAL; HOWEVER THIS INFORMATION WILL BE SHOWN TO THE INTENDED PARENTS, PSYCHOLOGISTS, AND PHYSICIANS.

INTENDED PARENT #1
First Name*
Last Name*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Date of Birth*
Date Format: MM slash DD slash YYYY
Occupation
Length of Employment
Employers Name
Address of Employer
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Have you ever been arrested?
- Yes
- No
If yes, were you convicted?
- Yes
- No
If yes, were you please explain.
INTENDED PARENT #2
First Name*
Last Name*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Date of Birth*
Date Format: MM slash DD slash YYYY
Occupation
Length of Employment
Address of Employer
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Have you ever been arrested?
- Yes
- No
If yes, were you convicted?
- Yes
- No
If yes, were you please explain.
Have either of you participated in a Psychological evaluation with respect to becoming involved in an assisted reproductive procedure?
- Yes
- No
If you answered yes, please provide the following information: Name of Evaluator
Name of the Clinic
Address of Clinic
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Please sign a Release to Rocky Mountain Surrogacy LLC and the evaluator to communicate with each other and for Rocky Mountain Surrogacy LLC to receive a copy of the evaluation. The release should be mailed or faxed to evaluator and to Rocky Mountain Surrogacy LLC as soon as possible.
Please indicate your status
- Single
- Married
- Life Partnership
- Date of Marriage of Commencement of Life Partnership
Please attach a copy of your marriage certificate of Marriage or Domestic Partnership.
Drop files here or
Do you have children living in your home?
- Yes
- No
Child #1 Name / DOB / Sex
Child #2 Name / DOB / Sex
Child #3 Name / DOB / Sex
Child #4 Name / DOB / Sex
Child #5 Name / DOB / Sex
Child #6 Name / DOB / Sex
What has led you to the decision of a gestational surrogate?
How many embryo transfers are you willing to undergo to achieve a successful pregnancy?
Do you wish for your gestational carrier to carry multiples?
- Yes
- No
If you answered yes, how many?
If the pregnancy is successful would you like the gestational carrier to carry another child for you in the future?
- Yes
- No
Are your embryos genetically tested or will they be?
- Yes
- No
Under what circumstances, if any, would you agree to abortion or selective reduction?
What is your timeframe for being introduced to a potential Gestational Carrier?
Please list the characteristics you are looking for in a gestational carrier:
Please describe the kind of relationship you hope to establish with the Gestational Carrier (before, during, and after the pregnancy):
Are you working with an attorney?
- Yes
- No
Attorney's Name
Attorney's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Attorney's Phone Number
Email
Has your attorney completed any documents for you relating to the assisted reproduction procedures?
- Yes
- No
If you answered yes, please indicate which documents have been completed and provide copies with this application.
Drop files here or
Are you currently working with a clinic?
- Yes
- No
If yes, please indicate the following: Name of clinic
Address of the clinic
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone number of the clinic
Name of Primary Nurse with whom you are working with:
What if any, arrangements have been made with the clinic for the type of assisted reproduction to be used?
How did you hear about Rocky Mountain Surrogacy LLC?
Please describe you and your family. You may want to include details about daily life and your family background. Please include a photo.
Please include a photo.
UNDERSTANDING in completing this application to Rocky Mountain Surrogacy, LLC, I/we understand that Rocky Mountain Surrogacy, LLC is not making a commitment that my/our Application will be accepted. I/we understand that a $1500.00 nonrefundable fee is due at the time of matching with a gestational carrier. I/we will sign all Release forms requested by Rocky Mountain Surrogacy, LLC in order for a determination to be made on our Application. I/we hereby consent to Rocky Mountain Surrogacy, LLC providing non-identifying information about me/us to potential Gestational Carriers prior to meeting with a Gestational Carrier. I/we understand that identifying information will not be released until I/we give specific authorization for such release. I/we agree to sign Releases for Rocky Mountain Surrogacy, LLC to communicate with any mental health professional conducting of having conducted a psychological evaluation relating to the assisted reproduction procedures in which I/we seek to engage with any of my/our medical care providers, and with the clinic I/we choose to conduct assisted reproductive procedures. The statements and commitments made in this Application are to the best of my/our knowledge and belief, correct and complete. I/we agree to provide additional information supplementing and updating the above answers if it comes to my/our attention, subsequent to the submission of this Application. I/we understand that if I/we knowingly provide false information on the Application it will be grounds for Rocky Mountain Surrogacy, LLC to refuse to accept me/us into the program or to refuse to work with me/us. Once accepted into the Program I/ we understand that the remaining agency fee is due at the Contract signing with your surrogate or at the time she starts medication for transfer (whichever event happens first). No transfer will be permitted without the agency fee being paid in full.*
- I Agree
Signature
Signature #2
Date
Date Format: MM slash DD slash YYYY

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