Maple Leaf Egg and Sperm Donor Registration Form
Name
First Name
Last Name
Sperm or Egg Donor:
*
Sperm Donor
Egg Donor
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (please add country code if outside Canada and USA)
Back
Next
Donor ID (Please Don't Fill out this Donor ID: Office Use Only)
Immigration Status
Canadian Citizen
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)
International
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
No
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
English
French
Chinese including Mandarin and Cantonese
Other
Emergency Contact Person Phone Number or Email
Donor Self Introduction
Please complete 5-6 sentences to introduce yourself:
Donor General Information
Education
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?
Health
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?
Personal
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?
Motivation
Have you ever been an egg or sperm donor? I so, was there a successful pregnancy?
Sexual Health
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 Traits
Family Member Demographic
Donor Picture
Donor Pictures (Please attached 8-10 high-definition pictures of you including childhood pictures, if possible)
Pictures Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Other Information if you prefer to sending to us
Submit
Should be Empty: