Donor Application

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Please provide the following contact information for: Applicant One (Female)

Address

City

State

Zip Code

Cell Phone

Home Phone

Work Phone

Social Security Number (Optional)

Email

Marital Status:MarriedEngagedLiving TogetherOtherSingleDivorcedWidowWidower

The Embryos Were Created By:

• Biological
• Egg Donor

(In this section use genetic information) Please Describe Biological/Genetic Characteristics Information of The Person Who Created the Egg:

Age at Time of Donation

Height

Weight

Hair ColorBlondeBrownBlackRedGrayWhite

Eye ColorBlueBrownBlackGreenGrayVioletHazel

Female Ethnic Background:VariousAsianAfrican-AmericanCaucasianEastern IndianEuropean/Various EuropeanWill ObtainOtherDon't Know

Hobbies and Interests

Education

Career/Occupation

Female Applicant's HealthExcellentGoodFairPoorOther

Other Comments

Please provide the following contact information for: Applicant Two (Male) In this section use Genetic Sperm information

Address

City

State

Zip Code

Cell Phone

Home Phone

Work Phone

Social Security Number (Optional)

Email

Biological or Sperm Donor?

• Biological
• Sperm Donor

Please Describe Biological/Genetic Characteristics Information of The Person Who Created the Embryo (Male Date of Birth):

Male Age at Time of Donation

Male Height

Male Weight

Hair Color BlondeBrownBlackRedGrayWhite

Eye Color BlueBrownBlackGreenGrayVioletHazel

Male Ethnic Background: VariousAsianAfrican-AmericanCaucasianEastern IndianEuropean/Various EuropeanWill ObtainOtherDon't Know

Hobbies and Interests

Education

Career/Occupation

Male Applicant's HealthExcellentGoodFairPoorOther

Other Male Health Comments

How quickly do you want to go in the process?As Quickly As PossibleA Year Would Be GreatJust Getting StartedWe Are Currently Pregnant So After Birth (Due Date)

Other Comments

Where Did You Hear ABout Embryos Alive?

Understanding of Embryo Donation

# of Embryos

# of Cells2 PN3 DayBlast5 Day Blast7 Day BlastNot SureOther

Year They Were Stored

Quality or Grade (if known)

Clinic Contact Name (if available)

Clinic Contact Email (if available)

Name of Doctor Who Did the IVF

What clinic did you use (What is the name of the clinic/facility we should contact where embryos and records are stored)?

Are they PGD/PGS tested?

• Yes
• No

How many female and how many male?

Did you have children from these embryos?

• Yes
• No

How many boys and how many girls? Ages? Children?

DONATION preferences About the RECIPIENT you would like Choose From The Following Options: Choosing of Recipient:EA Can Choose RecipientI/We Prefer To Choose RecipientOther

Married/Single or Surrogate:MarriedSingleOtherEither Married or SingleNeeds/Using a Surrogate to Carry

Comments

Age Preference of Adopters: Under 3030-4040-49Under 60No PreferenceCase-By-Case Basis

Number of Children (NOTE that some have adult children outside of the home or adopted):Case By Case BasisPrefer Someone With No Children123456More Than 10No Preference

Adoptors religion and level of importance:ChristianCatholicJewishNon-ChristianMuslimHinduBuddhistOther

Choose one of the following options:Regular AttendersPentecostal-Spirit FilledNon PracticingNot ImportantOther (Please Explain Below)

Comments Concerning Religion

Can Adoptors Be From Another Country?

Level Of Openness Preference With Adoptive Family of Embryos:Will Let The Adoptors DecideAfter 18Email OnlyAgency LiasonClosed/AnonymousCase By CaseNot SureOpen For Medical Reasons OnlyOther (Please Explain Below)

Other

Signature 1

Date

Signature 2

Submit

Visit for pros and cons of the levels of eligibility. Please email pictures! Adopters like to see what the baby/babies may look like!