Application - Intended Parent(s)

Intended Parent(s) Application

Let's start by gathering some information about you.
Applicant 1
Name:*

First NameLast Name
E-mail:*
Phone Number:*
Format: (000) 000-0000.
Is it okay to leave detailed messages related to surrogacy on this phone?*

YesNo
How can we best reach you?*

Call Phone Number ProvidedTextEmailOther
Address:*

Street Address

Street Address

CityState

Zip CodeCountry
Date of Birth:*

MonthDayYear
Date
Age:*
Are you based in the US (domestic) or International?*
Citizenship:*
Ethnicity:*
Are you religious?*

YesNo
If yes, what is your religion?:
Please indicate your relationship status:*

SingleIn a relationshipEngagedMarriedSeparatedDivorcedRegistered Domestic PartnershipWidowed
Date of Marriage or Registered Domestic Partnership:
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 pursuing surrogacy:*

InfertilitySecondary infertilityMedical conditionAgeSexual orientationOther
How long have you been trying to become a parent?*
How did you hear about Genesis Rising Surrogacy Center?*
Applicant 2
Name:

First NameLast Name
E-mail:
Phone Number:
Format: (000) 000-0000.
Is it okay to leave detailed messages related to surrogacy on this phone?

YesNo
How can we best reach you?

Call Phone Number ProvidedTextEmailOther
Address:

Street Address

Street Address

CityState

Zip CodeCountry
Date of Birth:

MonthDayYear
Date
Age:
Citizenship:
Ethnicity:
Are you religious?

YesNo
If yes, what is your religion?:
Occupation:
Annual Income:
Would you be willing to submit to a criminal background check?

YesNo
Reason(s) for pursuing surrogacy:

InfertilitySecondary infertilityMedical conditionAgeSexual orientationOther
How long have you been trying to become a parent?
General Information

Let's gather some information about your current situation.
Do you have children?*

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

YesNo
If yes, please tell us about your past experience with surrogacy. Did it result in a live birth? Please share if it was a good or a bad experience, and why.
Emergency Contact:

First NameLast Name
Emergency Contact Phone Number:
Format: (000) 000-0000.
Relationship to your emergency contact:
Are you financially prepared for the surrogacy process and reviewed the fees and expenses involved on our Costs of Surrogacy page?*

YesNo
What is your estimated budget?*
Health Insurance Information
If you are a resident of the United States, do you have health insurance coverage?*

YesNoI do not reside in the United States
Are you able to add your newborn to your insurance policy at birth?*

YesNoUnsure
Does your insurance plan have exclusions regarding surrogacy and delivery out of state?*

YesNoUnsure
Please upload an image of your insurance card

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You are required to purchase a health insurance plan for your newborn prior to the delivery or make arrangements to pay the hospital directly. Do you plan to purchase a health insurance plan for your newborn?*

YesNoUnsure
If no, what is your financial plan to pay for your baby's hospital expenses after delivery?*
Would you like a free consultation with an insurance broker to explain options to purchase newborn insurance?*

YesNoUndecided
Medical Information
Are you currently a patient at a fertility clinic?*

YesNo
If so, which one? Please provide name, address, phone number of the clinic.
Are you participating in a "guarantee" program with your clinic? If so, what is the program, and list any special requirements?
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 have embryos ready for transfer?*

YesNoIn the process of creating embryos
How many embryos do you have?*
Have they been genetically tested for chromosomal abnormalities? PGS or PGT-A tested?*

YesNoI'm not sure if my embryos are tested
What is the grade(s) of the embryo(s) you plan to transfer?
If you wish to match with a surrogate at the same time you are creating your embryos, please tell us about this:*
Are you using a donor?*

YesNo
What was the age of the woman (IP or donor) who contributed the egg when it was retrieved?*
Please indicate all that apply:*

Donor EggDonor SpermBothN/A
How many embryos are you planning to transfer per cycle? Please note, ASRM guidelines discourage transferring more than 1 embryo per cycle. *
Are you pursuing a dual journey?*

YesNoNot sureI don't know what this is
Are you currently signed with or actively working with another surrogacy agency who is also seeking a surrogate for you?*

YesNo
Please tell us about this:*
When would you like to match with a surrogate?*
Matching Preferences
Are there specific characteristics or qualities you are seeking in a Surrogate? Please describe:*
Do you require that your Surrogate is vaccinated against Covid-19?*

YesNoUnsure
Have you completed a "Dear Surrogate" letter or have video or another way to introduce your family to a surrogate?*

YesNoI'm not sure what this is
Often gestational surrogates like to share their surrogacy experience with online support groups and on social media. Are you supportive of your surrogate sharing her experience (while respecting your privacy with identity/photos)?*

YesNoUndecided
If your surrogate becomes pregnant with twins, would you want her to undergo selective reduction to reduce the number?*

YesNoUndecided
If your surrogate mother becomes pregnant with triplets or higher, would you want her to undergo selective reduction to reduce the number?*

YesNoUndecided
If your surrogate becomes pregnant with a fetus (or fetuses) that have chromosomal or physical irregularities or abnormalities, would you request that she terminate the pregnancy?*

YesNoUndecided
Discussing the termination of a pregnancy can feel uncomfortable, but we are using this information to appropriately match you with a surrogate who feels the same way about termination as you do. Please give us as much information as you can about your position:*
Please describe the level of involvement you would like with your surrogate up until your baby's delivery (such as attending doctor's visits, being present at the delivery, phone calls, texting, etc): *
Please describe the level of involvement you would like with your surrogate after the baby's delivery (stay in contact through updates, pictures, meet ups, social media, etc.)?*
Do you want your surrogate to pump breast milk for your baby?*

YesNoUnsure
If yes, for how long?
Do you plan to be open with your child/children about the circumstances of their conception and birth via surrogacy?*

YesNoUnsure
If your child requests to meet the surrogate in the future, how would you feel about that?*
When matching with a surrogate it is important for us to know what your "deal breakers" are and any situations where you would not feel comfortable matching with a surrogate. Please share your "deal breakers" here:*
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:
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 surrogate. 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 surrogates 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: cmurray@genesis-rising.org
Applicant 1: Picture of government issued identification such as driver's license or passport. *

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

Cancelof
Image of yourself, partner, or family.

Cancelof
Image of yourself, partner, or family.

Cancelof
Image of yourself, partner, or family.

Cancelof
Image of yourself, partner, or family.

Cancelof
Image of yourself, partner, or family.

Cancelof
Digital Signature

By typing your name(s) below, you acknowledge that you are signing this document electronically and that your signature will be binding. You also certify that your answers are correct and complete to the best of your knowledge.
Applicant 1: Digital Signature:*
Full Name
Date:*
Applicant 2: Digital Signature:
Full Name
Date:
Should be Empty:

Intended Parent(s) Application

Applicant 1

Applicant 2

General Information

Health Insurance Information

Medical Information

Matching Preferences

Legal

Escrow/Fund Management

Supporting Documentation

Digital Signature