2026 Surrogate Application Form-ASC
Surrogate Application
Begin Application
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Personal Information
1. Basic Compensation Preference
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$35,000–$65,000 for first-time surrogates; experienced surrogates may receive more.
2. Full Name
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First Name
Middle Name
Last Name
3. Age
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4a. Height in Feet
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If you're 5'2", enter: • Height (feet): 5 • Height (inches): 2
4b. Height in Inches
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5. Weight in Lbs
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6. City, State, Country
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7a. Occupation + Work Schedule
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Example: Caregiver, work Monday to Friday 8am-4pm
7b. Current Medical Insurance
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If you don't have one, enter "None"
8a. Relationship Status
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Please Select
Single
In a Stable Relationship
Married
Separated
Divorced
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8b. Spouse/Partner Name if Applicable
First Name
Last Name
8c. Spouse/Partner Occupation if Applicable
9. Household Members + Support Group + How Far
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Please list all household members (e.g. partner, children), your support group (e.g. parents, friends), and how far they live from you (e.g. “Mom – 10 miles away”)
10. Race
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Please Select
Caucasian
Hispanic
African American
Asian
Mixed
11. Parent's Ancestry
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Rows
Ethnicity
Mother's ethnicity
Mother's national origin
Father's ethnicity
Father's national origin
12a. Total Pregnancy Number
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12b. Live Birth Number
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12c. Miscarriage Number+Date
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("0" if not applicable)
12d. Abortion Number+Date
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("0" if not applicable)
12e. Number of Surrogacy Delivery Already Had
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Please Select
0
1
2
3
4
13. Children
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14a. Religion at Birth
14b. Practicing Religion
15a. Any Diet Restrictions
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15b. Drink Caffeine During Pregnancy?
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Please Select
Yes
No
15c. Do You Drink Any Alcoholic Beverages?
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Please Select
Yes
No
15d. Have You Ever Used Illicit Drugs or Smoke?
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Please Select
Yes
No
15e. Do You Do Exercise? If So, What Do You Do And Frequency?
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Example: Yes, hiking, once a month
15f. Do You Have Any Pets? If So, What Pets Do You Have?
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Example: Yes, 1 dog, 2 cats
16. Have You Had Any Tattoo/Piercing Done In The Past Year? If So, How Many Tattoos/Piercing?
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Example: Yes, 1 tattoo left arm
17. Do You Have Any Travel Plans In The Next Year?
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18. Are You Immune To?
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Hep B
Chickenpox
MMR
19. Date Of Marriage if Applicable
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Month
/
Day
Year
Date
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20–26. Have You Or Your Husband/Partner Ever:
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Rows
Yes
No
If Yes, Please Explain
20. Filed For Bankruptcy?
21. Been In A Psychiatric Facility?
22. Been Arrested?
23. Been Involved In Any Legal Cases, Or Any That Are Pending?
24. Been In A Substance Abuse Program?
25. Do You Drive?
26. Do You Own A Car Or Have Reliable Transportation?
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Medical/ Genetic Information
27. Were You Adopted?
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Rows
Yes
No
If So, Do You Have Information About Your Biological Parents?
Were You Adopted?
28. Blood Type:
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A+
B+
AB+
O+
A-
B-
AB-
O-
Unknown
29. Sexual Orientation:
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Example: Heterosexual, Homosexual, Etc.
30. Date Of Last OBGYN Visit:
31. Date of last Pap Smear + Result (Normal/Abnormal)
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Example: 06/09/2025, Normal
32. What Is Your Birth Control Method?
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Please Select
Abstinence
Condom
Birth Control Pill
IUD
Arm Implant
Others
33. Are You Currently Breastfeeding?
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Please Select
Yes
No
34a. Start And End Date Of Your Latest Period
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34b. Period Flow And Pain Level
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Example: Moderate Flow with Mild Cramping Pain
35–37. Please Select And Explain
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Rows
Yes
No
If So, Please Explain
35. Do You Have Regular Monthly Menstrual Cycles?
36. Has Your Weight Changed Dramatically In The Last Five Years For Reasons Other Than Pregnancy?
37. Are There Twins Or Triplets In Your Family?
38–45. Please Select And Explain
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Rows
Yes
No
If So, Please Explain
38. Are You Currently Sexually Active With Anyone Other Than Your Partner Listed On This Application?
39. Have You Ever Been Physically Abused?
40. Have You Ever Been Sexually Abused?
41. Have You Ever Had Thoughts Or Attempted Suicide?
42. Are You Taking Any Medications? Do You Have Any Allergies?
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43. Please List Any Hospitalizations, Surgeries, Or Plastic Surgeries You Have Had And The Dates Each Event Occurred:
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44. Have You Or Your Husband Or Partner Or Any Other Sexual Partners Ever Been Diagnosed With
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Rows
Yes
No
If Yes, Who
HIV
Chlamydia
Syphilis
Gonorrhea
HPV
Genital Herpes
Hepatitis B
Hepatitis C
Ovarian Cyst
PID
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Education/Employment
45. What Were Your Best Subjects In School?
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46. Highest Level Of Education Completed:
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Middle school
High school
Some college
Bachelor Degree
Master Degree
Doctorate Degree
47. Do You Have Plans On Furthering Your Education?
Characteristics
48. Please Describe Your Personality And Character:
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49. What Are Your Hobbies, Interests, And Talents?
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50. What Do You Like To Do In Your Spare Time?
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51. What Are Your Goals In Life?
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52. What Is The Reason You Want To Be A Surrogate Mother?
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53. Briefly Explain Your Understanding About How The Surrogacy Program Works?
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54. What Would You Consider Most Important In Choosing A Recipient Couple?
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55. What Relationship Do You Want To Have With The Intended Parents During Conception And Pregnancy?
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56. Would You Like To Meet The Recipient Couple?
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57. What Is The Maximum Number Of Embryos You Are Willing To Have Transferred At Each Appointment?
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Please Select
1
2
58. Are You Willing To Carry:
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Please Select
Singleton
Twins
Triplets
59. Would You Undergo A Selective Reduction Procedure If A Multiple Pregnancy Is Confirmed?
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Yes
No
60. If There Is A Medical Problem With The Pregnancy, Or With The Child You Are Carrying As A Surrogate And The Intended Parents Want To Consider Abortion, Would You Allow Them To Make That Decision Based On The Advice Of Their Physician And Personal Beliefs?
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61. Do You And Your Husband/Partner Understand That, Unless You Have Had A Tubal Ligation Or Your Husband/Partner Has Had A Vasectomy, You Must Agree To Abstain From Sexual Activity While Undergoing Medical Treatment And Participating In This Program?
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Yes
No
Your Email Address:
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example@example.com
I Swear Or Affirm That The Above And Foregoing Representations Are True And Correct To The Best Of My Information, Knowledge, And Belief.
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Please sign and date above the line
Date
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Month
-
Day
Year
Date
Please Upload 1-2 Happy, Family Style Photos Of Yours To Complete Your Application
Please verify that you are human
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