Surrogate Full Application

If you have been invited to complete the full surrogate application, please fill out the details below.

Full Name(Required)

Email(Required)

Phone(Required)

Date of Birth(Required)

Enter a date in mm/dd/yyyy format.

Height(Required)

Weight(Required)

How did you hear about us?(Required)

Place of Birth(Required)

Input a city and state / province like -- Atlanta, GA

Are you a US citizen or permanent resident?(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Country(Required)

Country

I am(Required)

Ancestry(Required)

Ethnicity(Required)

Spoke Language(s)(Required)

Religious Beliefs(Required)

Blood Type(Required)

Daily Caffeinated Beverages(Required)

Weekly Alcoholic Beverages(Required)

Do you smoke cigarettes, vape, or use any other nicotine / tobacco products?(Required)

Please Explain(Required)

Please explain your tobacco / nicotine usage.

Do you smoke weed or consume products containing marijuana?(Required)

Please Explain(Required)

Please explain your marijuana usage.

Not including marijuana, do you use recreational or illicit drugs?(Required)

Please Explain(Required)

Please explain any other drug use.

Did you get any piercings or tattoos within the last 6 months?(Required)

Please Explain(Required)

Please explain any piercings or tattoos.

Have you ever been convicted of a felony?(Required)

Please Explain(Required)

Please explain any felony details pertaining to you.

Has your partner or spouse ever been convicted of a felony?(Required)

Please Explain(Required)

Please explain any felony details pertaining to your partner our spouse.

Are you in a stable household and living situation?(Required)

Please Explain(Required)

Please explain the stability of your household situation since you selected no.

How many people living with you are over the age of 18?(Required)

My surrogate journey support system. Select all that apply(Required)

About me (provide a short bio to describe yourself)(Required)

My present and future goals(Required)

My favorite food(Required)

My favorite memory(Required)

My personality as a child(Required)

My favorite childhood activities(Required)

My Pets(Required)

My Favorite Color(s)(Required)

What made you want to become a surrogate?(Required)

If you could pass on a message to the family you’re helping, what would the message be?(Required)

Highest Level of Education(Required)

Field of Study(Required)

Institution(s)(Required)

Other Skills / Interests(Required)

Current Occupation(Required)

Exercise Habits(Required)

Have you applied or are you currently enrolled in another program?(Required)

Please Explain(Required)

Please explain the company or platform you applied to or are currently enrolled in.

Have you ever been screened for surrogacy?(Required)

Please Explain(Required)

Please explain any surrogacy screening you have gone through before.

Have you been a surrogate before?(Required)

Number of surrogacy journeys(Required)

For my surrogacy journey, I hope to work with(Required)

What level of communication do you hope to have with the family during pregnancy?(Required)

What level of communication do you hope to have with the family after pregnancy?(Required)

Are you open to having the parent(s) attend medical appointments / delivery?(Required)

Are you open to carrying twins?(Required)

Are you open to traveling outside of your state?(Required)

Are you open to providing breast milk for the baby after delivery?(Required)

I am interested in(Required)

Marital Status(Required)

Number of sexual partners within the last 6 months(Required)

Have you tested positive for any STIs/STDs in the past 6 months(Required)

My choice of birth control(Required)

How old were you when you started your period?(Required)

Date of last menstrual period(Required)

Enter a date in mm/dd/yyyy format.

Do you have monthly periods?(Required)

Are your periods regular when you are not on any type of hormonal birth control?(Required)

How many days does your period usually last?(Required)

Date of last Pap smear(Required)

Enter a date in mm/dd/yyyy format.

Have you ever had an abnormal Pap?(Required)

Have you been diagnosed with any common reproductive health disorders?(Required)

Number of Pregnancies(Required)

Type(Required)

Pregnancy 1 - Specify the pregnancy delivery type.

Date(Required)

Pregnancy 1 - Specify the date of birth for the child delivered.

Weeks(Required)

Please enter a number from 12 to 40.

Pregnancy 1 - Specify the number of weeks you carried.

Hours in Labor(Required)

Pregnancy 1 - Input the hours in labor.

Sex(Required)

Pregnancy 1 - Input the gender of the baby at the time of birth.

Type(Required)

Pregnancy 2 - Specify the pregnancy delivery type.

Date(Required)

Pregnancy 2 - Specify the date of birth for the child delivered.

Weeks(Required)

Please enter a number from 12 to 40.

Pregnancy 2 - Specify the number of weeks you carried.

Hours in Labor(Required)

Pregnancy 2 - Input the hours in labor.

Sex(Required)

Pregnancy 2 - Input the gender of the baby at the time of birth.

Type(Required)

Pregnancy 3 - Specify the pregnancy delivery type.

Date(Required)

Pregnancy 3 - Specify the date of birth for the child delivered.

Weeks(Required)

Please enter a number from 12 to 40.

Pregnancy 3 - Specify the number of weeks you carried.

Hours in Labor(Required)

Pregnancy 3 - Input the hours in labor.

Sex(Required)

Pregnancy 3 - Input the gender of the baby at the time of birth.

Type(Required)

Pregnancy 4 - Specify the pregnancy delivery type.

Date(Required)

Pregnancy 4 - Specify the date of birth for the child delivered.

Weeks(Required)

Please enter a number from 12 to 40.

Pregnancy 4 - Specify the number of weeks you carried.

Hours in Labor(Required)

Pregnancy 4 - Input the hours in labor.

Sex(Required)

Pregnancy 4 - Input the gender of the baby at the time of birth.

Type(Required)

Pregnancy 5 - Specify the pregnancy delivery type.

Date(Required)

Pregnancy 5 - Specify the date of birth for the child delivered.

Weeks(Required)

Please enter a number from 12 to 40.

Pregnancy 5 - Specify the number of weeks you carried.

Hours in Labor(Required)

Pregnancy 5 - Input the hours in labor.

Sex(Required)

Pregnancy 5 - Input the gender of the baby at the time of birth.

Type(Required)

Pregnancy 6 - Specify the pregnancy delivery type.

Date(Required)

Pregnancy 6 - Specify the date of birth for the child delivered.

Weeks(Required)

Please enter a number from 12 to 40.

Pregnancy 6 - Specify the number of weeks you carried.

Hours in Labor(Required)

Pregnancy 6 - Input the hours in labor.

Sex(Required)

Pregnancy 6 - Input the gender of the baby at the time of birth.

If you have had more than 6 pregnancies, we may ask you to fill out the same details you specified above within our mobile app or upon matching.

Have you ever had a miscarriage or any other complications during pregnancy/ childbirth?(Required)

Are you currently breastfeeding?(Required)

Do you want more children in the future?(Required)

Have you required an extended period of bed rest for any of your pregnancies?(Required)

Have you received the COVID-19 vaccine?(Required)

Have you ever tested positive for COVID-19?(Required)

Please provide the date and any treatment received.(Required)

In the past 6 months, have you been exposed to, tested positive, been diagnosed, or traveled to an area active with the Zika virus?(Required)

Please Explain(Required)

Explain the Zika virus diagnosis and details.

Do you have any allergies or intolerances?(Required)

Please Explain(Required)

Explain any allergies or intolerances.

Have you had any non-dental surgical procedures?(Required)

Please Explain(Required)

Explain any non-dental surgical procedures.

Have you had complications or concerns with anesthesia?(Required)

Please Explain(Required)

Explain any complications with anesthesia.

Are you currently being treated for a mental health disorder?(Required)

Please Explain(Required)

Explain any treatment for active mental health disorders.

Are you currently prescribed any antidepressants or anti-anxiety medications?(Required)

Please Explain(Required)

Explain any prescription details for antidepressants or anti-anxiety medications.

Have you ever sought medical treatment for depression, schizophrenia, psychosis and/ or personality disorders, addiction, suicide, anxiety, eating disorders, learning disabilities, bipolar disorder, autistic spectrum disorders?(Required)

Please Explain(Required)

Explain any medical treatment sought for depression or mental disorders noted above.

Have you received a Hepatitis B vaccine?(Required)

Have you ever had a blood transfusion?(Required)

Do you have any significant health concerns not yet mentioned?(Required)

Please Explain(Required)

Explain any significant health concerns not noted.

Do you have medical insurance?(Required)

Insurance Company Name(Required)

Estimated Effective Date(Required)

Type of Coverage(Required)

Premium Amount(Required)

Is the policy through an employer?(Required)

Does your policy cover surrogacy?(Required)

Are you receiving any government assistance? (welfare, disability, food stamps, etc.)(Required)

Please Explain(Required)

Explain any gov assistance you are receiving.

Terms(Required)

By checking this box you agree to our terms and privacy policy.

Authenticity of Application(Required)

I affirm and certify that all the information and answers to questions herein are complete, true, and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in the application may render this application void and I agree to receive messaging from Join Allkind Inc. regarding my application.

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