Golden Lotus VIP Egg and Sperm Donor Registration Form
Name
*
First Name
Last Name
Are you an egg or sperm donor
*
Egg donor
Sperm donor
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
You are from which Country
*
Phone Number (please add country code if outside Canada and USA)
Citizenship or Immigration Status, if you are living outside your home country
*
Are you able to travel to USA or Canada visa free
*
Yes
No
I need assitance to apply for a Visa to travel to USA or Canada
I can only donate in my own country and I cannot travel to USA or Canada
Which language(s) you speak and can communicate
*
English
French
Spanish
Chinese
Other
Emergency Contact Person Phone Number or Email
Have you ever been convicted of a crime or spent time in prison?
*
No
Yes
Not sure
If yes, please provide details, including the nature of the offense, the date of conviction, and any rehabilitation or legal steps taken since then:
Type a question
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? If so, was there a successful pregnancy?
Sexual Health
Sexual Health: Have you ever been diagnosed with any of the following?(leave it blank if you do not have any of these)
Have you or any direct family member ever been diagnosed with any of the following? (leave it blank if you do not have any of these illnesses)
Family Traits
Family Member Demographic
Please indicate Other (1) and Other (2) if you use them above
Donor Picture and/or 1-5 Minute Video
Donor Pictures (Please attached 8-10 high-definition pictures of you including childhood pictures, if possible)
Pictures Upload
*
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