Application for Intended Parents "*" indicates required fields Applicant InfoIP = Intended ParentIP 1* First Middle Last Maiden Name IP 1Preferred Pronouns IP 1*she, her, hershe, him, histhey, them, theirsLegal Name IP 1*Please type your legal name. All legal documents will reflect your name as indicated below. IP 2* First Middle Last Maiden Name IP 2Preferred Pronouns IP 2*she, her, hershe, him, histhey, them, theirsLegal Name IP 2*Please type your legal name. All legal documents will reflect your name as indicated below.Contact InfoAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Phone IP 1*Email IP 1* Date of Birth IP 1* Month Day Year Age IP 1*Are you a citizen of the United States IP 1* Yes No If no, are you a legal permanent resident IP 1* Yes No Phone IP 2*Email IP 2* Date of Birth IP 2* Month Day Year Age IP 2*Are you a citizen of the United States IP 2* Yes No If no, are you a legal permanent resident IP 2* Yes No Have you or your spouse ever been charged with child abuse allegations?* Yes No If yes, explainHave you or your spouse ever been convicted of a felony?* Yes No If yes, explainSurrogacy Program/ClinicName of Surrogacy ProgramContact at Surrogacy Program First Last PhoneEmail Is Surrogacy Program licensed in New York? Yes No Name of IVF Clinic*Contact at IVF Program* First Last Address of IVF Clinic*Phone*Email* Have you completed a medical evaluation IP 1* Yes No Have you completed a mental health evaluation IP 1* Yes No Have you completed a medical evaluation IP 2* Yes No Have you completed a mental health evaluation IP 2* Yes No ChildrenDo you have children?* Yes No If yes, how many?Ages of ChildrenEmploymentAre you currently employed IP 1* Yes No If so, Job Title IP 1Employer IP 1Are you currently employed IP 2* Yes No If so, Job Title IP 2Employer IP 2Embryo FormationSperm From: Intended Father Known Sperm Donor Anonymous Sperm Donor Name*Name of CryoBank*Egg From:* Intended Mother Know Egg Donor Anonymous Egg Donor Gestational Carrier Name*Name of Program*Embryo Donated From:List name(s) hereName of Gestational Carrier*Attorney For Gestational Carrier*Attorney's Phone*Attorney's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have insurance? Yes No Name of Medical Insurance ProviderIntended ParentsIs the Gestational Carrier known to you?* Yes No If yes, what is your relationship to her?If no, how did you learn about her?Required Documents /InformationPlease have the following documents ready to submit: Medical Insurance Review Last Will & Testament (addressing disposition of unused embryos and guardianship of children) Health Care Proxy/Durable Power of Attorney Life Insurance Supplemental InsurancePolicy/Health Supplemental Insurance Policy/Loss of Reproductive Organs Supplemental Insurance Policy/Disability Insurance Name of Estate Attorney drafting ancillary documents First Last Attorney PhoneAttorney Email Escrow Company*Name of Contact* First Last Contact Phone*Contact Email* SignaturesConsent IP 1* I certify that my answers are true and complete to the best of my knowledge.Consent IP 2* I certify that my answers are true and complete to the best of my knowledge.Date* Month Day Year CommentsThis field is for validation purposes and should be left unchanged.
