Application for Single Intended Parent "*" indicates required fields Applicant InfoName* First Middle Last Maiden Name Preferred Pronouns*she, her, hershe, him, histhey, them, theirsLegal Name* 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* Email* Date of Birth* Month Day Year Age* Are you a citizen of the United States?* Yes No If no, are you a legal permanent resident?* Yes No Have you ever been charged with child abuse allegations?* Yes No If yes, explainHave you ever been convicted of a felony?* Yes No If yes, explainSurrogacy Program/ClinicName of Surrogacy Program Contact 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?* Yes No Have you completed a mental health evaluation?* Yes No ChildrenDo you have children?* Yes No If yes, how many? Ages of Children EmploymentAre you currently employed?* Yes No If so, Job Title Employer Embryo 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) here Name 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 Provider Intended 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* I certify that my answers are true and complete to the best of my knowledge.Date* Month Day Year PhoneThis field is for validation purposes and should be left unchanged.
