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

Fields marked with an * are required

First name*

Last name

Intended Surrogate's date of birth*

Spouse's full name

Spouse's date of birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long have you lived at this address?

Phone

Email

Occupation

Work phone

Name of employer

Address of employer

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

First name only*

Surrogate's occupation*

Surrogate's monthly income*

Surrogate's height*

Surrogate's current weight*

Surrogate's race*

Are you a U.S. citizen?*

Current city you live in

Current state you live in

Intended Surrogate's date of birth*

What is your marital status?

Married
Single
Domestic Partnership
Divorced
Widowed
Separated

First name of your partner*

Partner's date of birth

Would you like to have children in the future?

Yes
No

What is your religious background?

Do you practice?

Yes
No

Do you have any couples or individuals that you would NOT be willing to work with?

Have you applied to other Surrogacy agencies?

Yes
No

How did you hear about us?

MANY CLINICS WILL REQUIRE YOU TO SEND YOUR LABOR AND DELIVERY RECORDS FROM THE HOSPITAL AND YOUR PRENATAL RECORDS FROM YOUR OB/GYN FOR ALL BIRTHS. PLEASE START REQUESTING THESE AT THIS TIME

Do you currently have health insurance?

Yes
No

If yes, what is your deductible?

What is your max out-of-pocket?

Is your insurance through an employer?

Yes
No

Who is your health insurance provider?

If you have any allergies, please list them below

Do you take any medications at this time? And why?

Please list the number of pregnancies you have had

How many of your pregnancies were live births?

How many of your pregnancies were miscarriages?

How many of your pregnancies were abortions?

Pregnancy #1: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds

Pregnancy #2: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds

Pregnancy #3: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds

Pregnancy #4: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds

Pregnancy #5: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds

Pregnancy #6: Name / DOB / Sex / Birth Weight / Length of Pregnancy / Type of Meds

If you experienced a miscarriage, please state the date and how far along you were

If you experienced an abortion, please state the date and how far along you were

Are your menstrual periods regular?

Yes
No

Is there anything unusual about your cycle? Please explain:

Are you currently on birth control?

Yes
No

If you are on birth control, what type?

Do you smoke?

Yes
No

Does anyone in your household smoke?

Yes
No

Have you ever used illegal drugs? If so, please list them below*

Do you have a criminal record?

Yes
No

Do you have a record of eating disorders?

Yes
No

Would you be willing to undergo an amniocentesis?

Yes
No

Would you be willing to terminate if the intended parents choose to?

Yes
No

What reasons would you not reduce or terminate?

Would you be willing to terminate if the pregnancy would result in a child with Down Syndrome?

Yes
No

What surgeries have you had and when?

Have you had any tattoos in the last 6 months?

Yes
No

Have you been seen by a professional for mental illness?

Yes
No

Have you experienced any postpartum depression?

Yes
No

Have you been prescribed any medication for mental illness?*

What is your blood type?

Rh Factor?

Yes
No

Have you delivered children with birth defects?

Yes
No

Are you with a sexual partner now?

Yes
No

How many sexual partners have you had in the past 3 years?

Have you had a sexually transmitted disease within the last 3 years?

Yes
No

Do you currently have more than one sexual partner?

Yes
No

What is the highest level of education you have completed?

What degrees or other trade experience do you have?

Briefly explain your understanding of what being a Gestational Carrier will entail?

Please describe yourself

What qualities would you consider most important that the intended parents have?

Why have you decided to become a Surrogate/Gestational carrier?

Would you allow the intended parents in the delivery room?

Yes
No

Would you allow the intended parents to attend doctor appointments?

Yes
No

Have you ever been a Surrogate/Gestational Carrier before? If yes, please explain your experience.

Have you ever placed a child up for adoption?

Yes
No

Are you adopted?

Yes
No

How do you feel about carrying Multiples? Twins or Triplets?

How much contact do you want following birth?

Do you feel confident that you will be able to give the intended parent(s) their child or children?

What type of support system do you expect to have through this experience?

All information provided in this application is true, accurate, and complete and to the Best of my knowledge.*

I agree

Signature

Date

I believe my wife/partner's response to this application is true, accurate and complete to The best of her knowledge. I am in support of her desire to become a gestational carrier.*

I agree

Significant Other/Husband

Date

A. Rocky Mountain Surrogacy, LLC did not induce, coerce me in my decision to become a gestational carrier*

I agree

B. Rocky Mountain Surrogacy, LLC is not a party to my agreement with the Intended Parents*

I agree

C. Rocky Mountain Surrogacy, LLC will be providing this application to potential parents both through hard copy and electronic formats. I acknowledge and agree that I will not be notified of such mailings and herby consent to the distribution of my application and photos to potential parents via mail and through electronic media such as email.*

I agree

D. Therefore, I hereby agree to release and discharge Rocky Mountain Surrogacy, LLC and any of its representatives, agents, employees, and servants from all liability and all manners of action, suits, causes of actions, proceedings, debts, contracts, judgments, damages, claims, and demands whatsoever in law or equity in connection with my decision to become a gestational carrier or any adverse consequences which may arise in my connection with or as a result of my participation with this process. I hereby further agree to indemnify Rocky Mountain Surrogacy, LLC against any and all costs incurred in defending any such actions arising of this process. In the event that testing or screening has been completed and I choose not to move forward with the process I understand that any fees incurred on my behalf is my responsibility.*

I agree

Applicant

Date

If you have any questions about any information requested in this Application feel free to call us at (208) 284-7748 or ask below.

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