Application - Intended Parent(s)

Egg Donation: Intended Parent(s) Application

Let's start by gathering some information about you.
Who can we thank for referring you?*
Applicant 1
Name:*

First NameLast Name
Language Preference
E-mail:*
Cell Phone Number:*

Country CodeArea CodePhone Number
Is it okay to leave detailed messages related to egg donation on this phone?*

YesNo
How can we best reach you?*

Cell Phone Number ProvidedTextEmailOther
Address:*

Street Address

Street Address

CityState

Zip CodeCountry
Date of Birth:*

MonthDayYear
Date
Age:*
Citizenship:*
Ethnic background:*
Are you religious?*

YesNo
If yes, what is your religion?:
Occupation:*
Annual Income:
Have you ever:*

Been charged with child abuse or neglect?Been in a substance abuse program?Been arrested?Filed for bankruptcy?None
If you marked any of the above, please provide dates of the event(s):
Would you be willing to submit to a criminal background check?*

YesNo
Reason(s) for seeking a donor:*

InfertilityMedical conditionSexual orientationAgeOther
If you marked "other" please explain:
How long have you been trying to become a parent?*
Do you have a Will or Trust?*

YesNoWorking on It
Applicant 2

Single applicants - please leave this section blank.
Applicant 2:

First NameLast Name
Language Preference
E-mail:
Cell Phone Number?

Country CodeArea CodePhone Number
Is it okay to leave detailed messages related to egg donation on this phone?

YesNo
How can we best reach you?

Cell Phone Number ProvidedTextEmailOther
Address:

Street Address

Street Address

CityState

Zip CodeCountry
Date of Birth:

MonthDayYear
Date
Age:
Citizenship:
Ethnic background:
Are you religious?

YesNo
If yes, what is your religion?:
Occupation:
Annual Income:
Have you ever:

Been charged with child abuse or neglect?Been in a substance abuse program?Been arrested?Filed for bankruptcy?None
If you marked any of the above, please provide dates of the event(s):
Would you be willing to submit to a criminal background check?

YesNo
How long have you been trying to become a parent?
Reason(s) for seeking a donor:

InfertilityMedical conditionSexual orientationAgeOther
If you marked "other" please explain:
Do you have a Will or Trust?

YesNoWorking on It
General Information

Let's gather some information about your current situation.
Please indicate your relationship status:*

SingleIn a relationshipEngagedMarriedSeparatedDivorcedRegistered Domestic PartnershipWidowed
Date of Marriage or Registered Domestic Partnership?
Do you have children?*

YesNo
If yes, please provide their gender, age, and if they are biological or resulted from surrogacy or adoption:
Have you pursued egg donation in the past?*

YesNo
If yes, please tell us about your past experience with egg donation. Did it result in a live birth, was it a good or bad experience and why, etc.
Emergency Contact:

First NameLast Name
Emergency Contact Phone Number:

Area CodePhone Number
Relationship to your emergency contact:
Are you financially prepared for the egg donation process and reviewed the fees and expenses involved?*

YesNo
What is your estimated budget?*
Medical Information
Who's sperm do you plan on using? *
Are you a patient at a fertility clinic?*

YesNo
If so, which one? Please provide name, address, phone number of the clinic.
Please provide the name of your IVF doctor:
Please provide the name of the Nurse if you know it.
What medical interventions (if any) have you tried so far?*
Do you plan on pursuing surrogacy?*

YesNoUnsure
When you have embryos ready for transfer, do you plan on getting them genetically tested for chromosomal abnormalities? PGS or PGT-A tested?

YesNoI'm not sure if I will get my embryos tested
Matching Preferences
Are there specific characteristics or qualities you are seeking in an egg donor? Please describe:*
Do you require that your Egg Donor be vaccinated against Covid-19?
Often egg donors like to share their experience with online support groups and on social media. Are you supportive of your egg donor sharing her experience (while respecting your privacy with identity/photos)?*

YesNoUndecided
What type of egg donor arrangement are you seeking?*

Known (someone you know personally)Anonymous (donor and IPs have no identifying information about the other)Semi-open (limited information shared with option to share more once child is 18)Open (identifying information is shared for open communication)I haven't decidedI need more information
Do you plan to share your child/children that he/she/they were donor conceived?*

YesNoUnsure
If your child requests to meet the egg donor in the future, how would you feel about that?*
Is there anything you would like us to know about your matching preferences or your situation in general? Feel free to leave a comment below:
Legal
Are you working with or have you identified an attorney who specializes in assisted reproduction?*

YesNo
If so, please provide the name of your attorney and contact information for the law firm:
If not, we will set you up with one that we recommend.
Escrow/Fund Management
Are you working with or have you identified an escrow management company? Please note that Genesis Rising Surrogacy Center does not allow escrow to be held by an attorney or law firm who represents either you as the intended parent(s) or the egg donor. It must be held by a disinterested 3rd party.*

YesNo
If so, please provide the name of the escrow management company and contact information:
Supporting Documentation

Please provide us with proof of your identify (this is for our records only and will remain confidential) as well as several family photos to share with prospective egg donors during the matching process. If you are having issues sending the photos via this form we will follow up by email to receive a copy. If you prefer to send them via email please send to: admin@genesis-rising.org
Applicant 1: Picture of government issued identification such as driver's license or passport.

Browse Files

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Applicant 2: Picture of government issued identification such as driver's license or passport.

Browse Files

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Release and Warranties

Genesis Rising Surrogacy Center will ensure my/our Application and the information I/we provided with it to be kept strictly confidential unless I/we have given expressed permission for it to be shared with a prospective egg donor or surrogacy professional (IVF clinic/doctor/lawyer/psychologist/social worker).
Digital Signature

By typing your name(s) below, you acknowledge that you are signing this document electronically.
Applicant 1: Digital Signature:*
Full Name
Date:*
Applicant 2: Digital Signature:
Full Name
Date:
Payment

There is a $350 Application Fee due at the submission of this document. Once paid, you will be considered a registered family with our Agency and will receive priority matching for waiting egg donors who meet your matching criteria.
Payment*
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Application Fee$350.00

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Egg Donation: Intended Parent(s) Application

Applicant 1

Applicant 2

General Information

Medical Information

Matching Preferences

Legal

Escrow/Fund Management

Supporting Documentation

Release and Warranties

Digital Signature

Payment