Surrogate Application
Please complete this form to the best of your ability. We will contact you shortly after submission.
Name:
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First Name
Last Name
E-mail:
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example@example.com
Re-type E-mail:
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example@example.com
What's your phone number?
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When is the best time to contact you?
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What is the best way for us to reach you?
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Phone
Text
Email
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
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Google/Internet search
TikTok
Instagram
Facebook
Another surrogate
Word of mouth
Other
What is your State of residence?
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Birth Date
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How old are you?
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What is your current legal status in the United States?
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U.S. Citizen
Lawful Permanent Resident (Green Card holder)
DACA (Deferred Action for Childhood Arrivals)
TPS (Temporary Protected Status)
Asylum or Refugee
Work Visa
Other
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):
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Hispanic/Latino
African American
Caucasian
Indian (non Native American)
Native American/Alaskan Native
Pacific Islander
Middle Eastern
Asian
Other
What is your relationship status?
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Please Select
Single
In a relationship (not living together)
In a relationship (living together)
Legally married
Legally married, separated
When and where were you married?
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What is your spouse/partner's full name?
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What is your spouse/partner's date of birth?
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Phone Number of Spouse/Partner
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-
Area Code
Phone Number
Email of Spouse/Partner
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example@example.com
Is your spouse/partner aware of and supportive of your interest in becoming a surrogate?
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Please Select
Yes
No
It's complicated
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?
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Yes
No
Congrats! Please tell us about your experience:
Have you ever been denied by another surrogacy agency?
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Yes
No
Please tell us about the circumstances. What were the reasons?
Please tell us why you want to be a surrogate?
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Health Information
How many vaginal births have you had?
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Please Select
0
1
2
3
4
5
6+
How many C-sections have you had?
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Please Select
0
1
2
3
4+
Please list the dates of live births, as well as how many weeks along you were at delivery?:
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Have you had any miscarriages?
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Yes
No
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?
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Yes
No
Undecided
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.
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Pre-Eclampsia
High Blood Pressure
Pre-term delivery (prior to 37 weeks gestation)
Fetal Growth Restriction
HSV Positive (herpes symplex virus)
Bed rest for singleton pregnancy
PIH (pregnancy induced hypertension)
Hyperthyroidism
Gestational Diabetes - controlled by diet
Gestational Diabetes - prescribed medication
None of the Above
Please mark all that apply:
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Abnormal pap smear
HIV Diagnosis
Hepatitis B
Untreated Hepatitis C
Bi-Polar disorder
3 or more C-Sections
Criminal history
Gastric bypass surgery
A body piercing or tatoo in the last 6 months?
Taking medication for Depression
5 or more total deliveries
Had your tubes tied (Adiana or Essure procedure)
Taking medication for anxiety
Drug addiction and/or rehab
Post-partum depression
Consumed tobacco/marijuana products in the last 6 months
Prior smoker
None of the above
Please give the approximate month/year of your last pap smear:
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What is your height?
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What is your current weight?
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Are you willing to administer self injectable medications?
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Yes
No
Do you currently use tobacco products (cigarettes, e-cigarettes, etc?)
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No
Yes
Do you use marijuana products that contain THC (smoke joints, vape, edibles, etc?)
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No
Yes
Are you a previous smoker?
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No
Yes
Are you vaccinated against COVID 19?
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Yes
No
Are you willing to get the booster if the IP(s) clinic requests it?
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Yes
No
Unsure
Are you willing to receive the vaccination in order to be matched?
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Yes
No
Unsure
Do you have a partner or spouse residing with you who is joining you on your surrogacy contract?
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Yes
No
Name of partner/spouse:
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First Name
Last Name
Who do you currently live with? Mark all that apply:
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Partner/spouse
Child/ren
Your parent(s)
Roommates
I live alone
Other
Please list all individuals over the age of 18 who live with you.
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Have you, or anyone in your household, ever been arrested or convicted of a crime? If yes, please explain:
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What type of birth control are you using to prevent pregnancy?
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Education and Occupation
Are you currently a student?
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Yes
No
Highest level of education?
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High School
Some college
Bachelor's Degree
Master's Degree
PhD.
Technical/trade school
Cosmetology/beauty
Other
Are you currently employed?
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Yes
No
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)?
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No
Yes
Do you have health insurance?
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Yes
No
What is the name of your insurance carrier?
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Do you know if you can use it for a surrogate pregnancy?
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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?
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Are you able and willing to travel?
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Are you willing to carry twins?
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Yes
No
If no, are you willing to carry twins if the embryo splits in utero?
Yes
No
Clinics typically only allow one embryo transfer per cycle.
Are you willing to selectively reduce?
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Yes
No
I don't understand what selective reduction is.
Only applicable if the embryo splits.
Do you have a valid driver's license?
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Yes
No
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?
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Yes
No
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
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Date:
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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."
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Yes
No
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.
*
Yes
No
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:
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Yes
No
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