Maple Leaf Egg and Sperm Donor Registration Form
Street Address Line 2
State / Province
Postal / Zip Code
Phone Number (please add country code if outside Canada and USA)
Canadian Permanent Resident
Work Permit with Provincial Health Coverage, for example OHIP
Study Permit with University Health Coverage, for example, UHIP
Traveller to Canada (Visitor Visa or Extended Visitor Permit)
If you are not eligible for any Canadian provincial health plan, do you have any medical insurance coverage in Canada :
Yes, for example, medical insurance with Canadian universities, if you are studying in Canada or medical insurance with Canadian employer, if you work for Canadian employer
Other, for example, I have medical insurance coverage in the USA.
Not applicable to me because I have health card from one of Canadian provincie or territory
Which language(s) you speak and can communicate
Chinese including Mandarin and Cantonese
Emergency Contact Person Phone Number or Email
Donor Self Introduction
Please complete 5-6 sentences to introduce yourself:
Donor General Information
What is the highest level of schooling attained? High school graduate I some college I technical school I Bachelor’s degree I some graduate school I Master’s degree I Doctorate?
Did you attend college I university? If yes, what did you study?
What were your favorite subjects in school?
What is your current profession?
What are your future career goals?
Have you ever been pregnant?
Is there a history of multiple births in your family?
Do you have allergies?
Do you smoke? If yes, how many per day?
Do you drink alcohol? If yes, how many glasses per week?
Do you take recreational drugs? If yes, please explain.
Have you ever been treated for drug or alcohol abuse?
At time of donation, are you taking any medication or supplements?
At time of donation, are you under the care of a physician? If so, for what?
How do people describe you? What are your main personality traits? List at least 3.
What are your hobbies and interests? List at least 3.
What are your future life goals and aspirations?
What is your biggest fear?
What skills or talents do you have? For example, musical I artistic I athletic?
Have you ever been an egg or sperm donor? I so, was there a successful pregnancy?
Sexual HealthHave you ever been diagnosed with any of the following?(You need to type No even though you never have any)
Have you or any direct family member ever been diagnosed with any of the following? (You need to type No even though you never have any)
Family Member Demographic
Donor Pictures (Please attached 8-10 high-definition pictures of you including childhood pictures, if possible)
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Choose a file
Other Information if you prefer to sending to us
Should be Empty: