Application Form - Gestational Carrier

Surrogate Application

Please complete this form to the best of your ability. We will contact you shortly after submission.
Name:*

First NameLast Name
E-mail:*
example@example.com
Re-type E-mail:*
example@example.com
What's your phone number?*
When is the best time to contact you?*
What is the best way for us to reach you?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?*
What is your State of residence?*
Birth Date*
How old are you?*
What is your current legal status in the United States? *
Your responses are confidential and used only to verify your eligibility to participate in our surrogacy program.
What is your Ethnicity (mark as many as applicable):*

Hispanic/LatinoAfrican AmericanCaucasianIndian (non Native American)Native American/Alaskan NativePacific IslanderMiddle EasternAsianOther
What is your relationship status?*
When and where were you married?*
What is your spouse/partner's full name?*
What is your spouse/partner's date of birth?*
Phone Number of Spouse/Partner*

Area CodePhone Number
Email of Spouse/Partner*
example@example.com
Is your spouse/partner aware of and supportive of your interest in becoming a surrogate?*
Would you like to share any additional comments about your spouse/partner's involvement, support, or areas of concern?
Have you been a gestational surrogate before?*

YesNo
Congrats! Please tell us about your experience:
Have you ever been denied by another surrogacy agency?*

YesNo
Please tell us about the circumstances. What were the reasons?
Please tell us why you want to be a surrogate?*
Health Information
How many vaginal births have you had?*
How many C-sections have you had?*
Please list the dates of live births, as well as how many weeks along you were at delivery?:*
Have you had any miscarriages?*

YesNo
Please provide additional details:
This information helps our medical review team better understand your history.If known, please include year, gestational age, whether the miscarriage was spontaneous or medically managed, and any known or suspected cause.
Are you willing to terminate a pregnancy if the fetus has abnormalities and/if the intended parent(s) ask you to?*

YesNoUndecided
Please share your thoughts and/or concerns regarding termination.
We want to be transparent that most intended parents require that pregnancy termination remain an available option in certain medical situations. For this reason, differing views on this topic can impact matching opportunities.
Have you experienced any of the following? Mark all that apply.*

Pre-EclampsiaHigh Blood PressurePre-term delivery (prior to 37 weeks gestation)Fetal Growth RestrictionHSV Positive (herpes symplex virus)Bed rest for singleton pregnancyPIH (pregnancy induced hypertension)HyperthyroidismGestational Diabetes - controlled by dietGestational Diabetes - prescribed medicationNone of the Above
Please mark all that apply:*

Abnormal pap smearHIV DiagnosisHepatitis BUntreated Hepatitis CBi-Polar disorder3 or more C-SectionsCriminal historyGastric bypass surgeryA body piercing or tatoo in the last 6 months?Taking medication for Depression5 or more total deliveriesHad your tubes tied (Adiana or Essure procedure)Taking medication for anxietyDrug addiction and/or rehabPost-partum depressionConsumed tobacco/marijuana products in the last 6 monthsPrior smokerNone of the above
Please give the approximate month/year of your last pap smear:*
What is your height?*
What is your current weight?*
Are you willing to administer self injectable medications?*
Do you currently use tobacco products (cigarettes, e-cigarettes, etc?)*
Do you use marijuana products that contain THC (smoke joints, vape, edibles, etc?)*
Are you a previous smoker?*
Are you vaccinated against COVID 19?*

YesNo
Are you willing to get the booster if the IP(s) clinic requests it?*

YesNoUnsure
Are you willing to receive the vaccination in order to be matched?*

YesNoUnsure
Do you have a partner or spouse residing with you who is joining you on your surrogacy contract?*

YesNo
Name of partner/spouse:*

First NameLast Name
Who do you currently live with? Mark all that apply:*

Partner/spouseChild/renYour parent(s)RoommatesI live aloneOther
Please list all individuals over the age of 18 who live with you. *
Have you, or anyone in your household, ever been arrested or convicted of a crime? If yes, please explain:*
What type of birth control are you using to prevent pregnancy?*
Education and Occupation
Are you currently a student?*
Highest level of education?*
Are you currently employed?*
Where do you work?
What is your job title?
How many hours per week do you work?
What is your hourly wage? If salary, how much per pay period?
Are you currently receiving any form of public assistance (food stamps, Medicaid, welfare, housing assistance,etc)?*
Do you have health insurance?*

YesNo
What is the name of your insurance carrier?*
Do you know if you can use it for a surrogate pregnancy?*
Please upload a copy of the front of your insurance card here:

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Please upload a copy of the back of your insurance card here:

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Upload a copy of your most recent paystub here:

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Matching Preferences
What type of family do you want to carry for?*
Are you able and willing to travel?*
Are you willing to carry twins?*
If no, are you willing to carry twins if the embryo splits in utero?
Clinics typically only allow one embryo transfer per cycle.
Are you willing to selectively reduce?*
Only applicable if the embryo splits.
Do you have a valid driver's license?*
If yes, please upload a copy of your driver's license below:
Upload copy of the front your driver's license or State ID here:*

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Do you have reliable transportation?*
Please upload photos that will be used on your matching profile.

These should be photos you would feel comfortable using on a job application, use natural light, have no face altering filters, wear modest clothing.
A photo of yourself.

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A photo of you and your children.

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A photo of you and your partner (with your child/ren is fine), or someone who is your support during this journey.

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A photo just for fun.

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Another great photo if you can't decide.

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Digital Signature
Signature*
Date:*
Texting Permission: I consent to receive text messages from Genesis Rising regarding my application, appointments, and case updates. Message frequency varies. Msg & data rates may apply. Consent is not required to complete my application. Reply HELP to get support, reply STOP to opt out."*

YesNo
Phone/Email Permission: I consent to receive phone calls and/or emails from Genesis Rising regarding my application, appointments, and case updates. Msg & data rates may apply. Consent is not required to complete my application.*

YesNo
Terms & Conditions and Privacy Policy

By providing your phone number and opting in, you agree to receive SMS text messages from Genesis Rising related to surrogacy program updates, application status updates, appointment reminders, educational information about surrogacy, and occasional promotional messages. Message frequency varies, but you may receive up to 2 messages per week. Message and data rates may apply depending on your mobile carrier plan. For assistance, text HELP for help or contact us at our website.To stop receiving messages at any time, text STOP to stop. After you send the STOP message, we will confirm your unsubscribe status via SMS and you will no longer receive SMS messages from us. For more information, please review our: Privacy Policy: https://www.genesisrising.com/privacy Terms & Conditions: https://www.genesisrising.com/terms-conditions. By checking the box and submitting this form, you confirm that you have read and agree to the Privacy Policy and Terms & Conditions and consent to receive SMS communications from Genesis Rising. Consent is not a condition of purchase.
Terms & Conditions and Privacy Policy As Stated Above:*

YesNo
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