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Apply to be a Surrogate
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Full name
*
First
Last
Email
*
Phone Number
*
Date of birth
*
mm/dd/yyyy
Best way to contact you
*
Phone
Text
Email
Location
*
City, State
Do you have reliable transportation?
*
Yes
No
What is your ethnicity?
*
What is your religious affiliation?
*
What is your highest form of education?
*
Less than high school diploma
High school diploma or GED
Some college/ no degree
Associates degree
Bachelor degree
Masters degree
Higher than above listed
Height
*
Feet, inches
Weight
*
in LBS
Blood type
*
Are you currently taking medications?
*
If yes, please detail what medications. This includes all forms of birth control
Allergies
*
Yes
No
If Yes, what allergies?
Do you smoke cigarettes, use any nicotine, THC products, or any form of recreational or illegal drugs/ substances?
*
Yes
No
There are extensive drug and nicotine screenings
you you many
Do you drink alcoholic beverages If so how often? *(Please note that once you start your IVF medication before a transfer and while pregnant you may not drink alcohol.)
Do you have any history of substance abuse, or have you ever been in a substance abuse program? If so, please explain.
*
Have you ever been in a psychiatric facility? If so Please Explain.
*
Have you had any tattoos or piercings in the last 12 months?
*
Yes
No
Are you currently breastfeeding?
*
Yes
No
Are your menstrual cycles regular?
*
Yes
No
Date of last menstrual cycle
*
mm/dd/yyyy
How many days between menstrual cycles
*
Date of you most recent pap smear
*
mm/dd/yyyy
Do you have a history of STI's? If so, what STI's and when (if) were you cleared?
*
Past surgeries
*
List any previous surgeries
How many pregnancies total?
*
Including miscarriages, abortion
List of all deliveries, including weeks at date of delivery, and delivery dates
*
Have you have any difficulty getting pregnant?
*
Yes
No
Have you ever had any pregnancy complications? If so, what?
*
During pregnancy have you ever had any of the following
*
High blood pressure
Toxemia
Anemia
Preeclampsia
Pre-term labor
Premature rupture of membranes
Placenta acreta
Placenta abruption
Hyper emis
Hemorrhaging in labor
Infection
N/A
How long have you been considering Surrogacy?
*
Describe your diet
*
Do you eat out or cook at home
What forms of exercise do you do and how often?
*
Are you planning on continuing while pregnant
Select all of the following intended parents you will consider
Any couple
Married couple
Same-sex couple
Single parent
Caucasian
Hispanic
Asian
African American
Any race
With no children
with children
Frequent communication
No communication
Contact after birth
No contact after birth
Do you have previous experience as a Surrogate?
*
Yes
No
Are you willing to completely refrain from the use of alcohol, tobacco, marijuana, illegal drugs, and medications not authorized by a doctor during this surrogacy?
*
Yes
No
Do you have history of substance abuse?
*
Yes
No
Are you willing to reduce or eliminate your caffeine intake while you’re pregnant? (e.g. tea, coffee, energy drinks and soda)
*
Yes
No
During the pregnancy you will not be permitted to travel outside of your state after approximately 20 weeks of pregnancy. Will this be feasible for you?
*
Yes
No
If serious health problems, genetic malformations or birth defects were detected during the pregnancy, would you be willing to terminate at the request of the intended parents?
*
Yes
No
When a transfer results in a pregnancy of more than twins many physicians recommend selective reduction and many intended parents prefer to reduce the pregnancy to twins. Are you willing to undergo a selective reduction to twins to increase the chances of survival for the remaining babies and for your safety and well-being?
*
Yes
No
Are you willing to travel out of the state, for the transfer, for up to 5 days?
*
Yes
No
Will you be willing to allow the intended parents to attend appointments and delivery?
*
Yes
No
Some surrogates pump breast milk following the delivery and are compensated by the intended parents. Are you interested in pumping for your surrogate baby?
*
Yes
No
Some intended parents live far away from their surrogates. If your intended parents can’t see you regularly make it to appointments or delivery would that be okay with you?
*
Yes
No
Are you willing to come to the Los Angeles area for your OBGYN screening and preparation.*(Travel expenses will be reimbursed)
*
Yes
No
What is your occupation?
*
Describe your lifestyle, hobbies, etc.
*
Describe your home life
*
Are you a US citizen?
*
Yes
No
Do you have a valid drivers license?
*
Yes
No
Have you ever filed for bankruptcy?
*
Yes
No
Do you have a criminal history?
*
Yes
No
Have you ever been arrested? If so, explain
*
Do you have American Indian heritage?
*
Yes
No
Relationship status
*
Single
Relationship
Married
Divorced
Spouse/ partners name
*
First
Last
Spouse/ partners date of birth
*
mm/dd/yyyy
Does your partner have a history of substance abuse?
*
Yes
No
Does your partner have a history of psychiatric care?
*
Yes
No
Do you have a local support system?
*
Yes
No
Is there anyone in your support group that does not support your choice to become a Surrogate?
*
Yes
No
Who currently resides in your home?
*
How many sexual partners have you had in the last 6 months?
*
What compensation are you hoping for for your journey?
*
Describe why you are interested in becoming a Surrogate?
*
Submit
Blessing Surrogacy Surrogate Application
Blessing Surrogacy passionately brings together Intended Parents and Surrogates worldwide, dedicated to uniting families. Our mission is to diligently match Surrogates and Intended Parents, ensuring compatibility and fostering a journey of love, joy, and shared happiness for all involved.
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Full name
*
First
Last
Email
*
Phone Number
*
Spouse/ well-being?
Date of birth
*
mm/dd/yyyy
Best way to contact you
*
Phone
Text
Email
Location
*
City, State
Do you have reliable transportation?
*
Yes
No
What is your ethnicity?
*
What is your religious affiliation?
*
What is your highest form of education?
*
Less than high school diploma
High school diploma or GED
Some college/ no degree
Associates degree
Bachelor degree
Masters degree
Higher than above listed
Height
*
Feet, inches
Weight
*
in LBS
Blood type
*
Are you currently taking medications?
*
If yes, please detail what medications. This includes all forms of birth control
Allergies
*
Yes
No
If Yes, what allergies?
Do you smoke cigarettes, use any nicotine, THC products, or any form of recreational or illegal drugs/ substances?
*
Yes
No
There are extensive drug and nicotine screenings
Do you drink alcoholic beverages If so how often? *(Please note that once you start your IVF medication before a transfer and while pregnant you may not drink alcohol.)
Do you have any history of substance abuse, or have you ever been in a substance abuse program? If so, please explain.
*
Have you ever been in a psychiatric facility? If so Please Explain.
*
Have you had any tattoos or piercings in the last 12 months?
*
Yes
No
Are you currently breastfeeding?
*
Yes
No
Are your menstrual cycles regular?
*
Yes
No
Date of last menstrual cycle
*
mm/dd/yyyy
How many days between menstrual cycles
*
Date of you most recent pap smear
*
mm/dd/yyyy
Do you have a history of STI's? If so, what STI's and when (if) were you cleared?
*
Past surgeries
*
List any previous surgeries
How many pregnancies total?
*
Including miscarriages, abortion
List of all deliveries, including weeks at date of delivery, and delivery dates
*
Have you have any difficulty getting pregnant?
*
Yes
No
Have you ever had any pregnancy complications? If so, what?
*
During pregnancy have you ever had any of the following
*
High blood pressure
Toxemia
Anemia
Preeclampsia
Pre-term labor
Premature rupture of membranes
Placenta acreta
Placenta abruption
Hyper emis
Hemorrhaging in labor
Infection
N/A
How long have you been considering Surrogacy?
*
Describe your diet
*
Do you eat out or cook at home
What forms of exercise do you do and how often?
*
Are you planning on continuing while pregnant
Select all of the following intended parents you will consider
Any couple
Married couple
Same-sex couple
Single parent
Caucasian
Hispanic
Asian
African American
Any race
With no children
with children
Frequent communication
No communication
Contact after birth
No contact after birth
Do you have previous experience as a Surrogate?
*
Yes
No
Are you willing to completely refrain from the use of alcohol, tobacco, marijuana, illegal drugs, and medications not authorized by a doctor during this surrogacy?
*
Yes
No
Do you have history of substance abuse?
*
Yes
No
Are you willing to reduce or eliminate your caffeine intake while you’re pregnant? (e.g. tea, coffee, energy drinks and soda)
*
Yes
No
During the pregnancy you will not be permitted to travel outside of your state after approximately 20 weeks of pregnancy. Will this be feasible for you?
*
Yes
No
If serious health problems, genetic malformations or birth defects were detected during the pregnancy, would you be willing to terminate at the request of the intended parents?
*
Yes
No
When a transfer results in a pregnancy of more than twins many physicians recommend selective reduction and many intended parents prefer to reduce the pregnancy to twins. Are you willing to undergo a selective reduction to twins to increase the chances of survival for the remaining babies and for your safety and well-being?
*
Yes
No
Are you willing to travel out of the state, for the transfer, for up to 5 days?
*
Yes
No
Will you be willing to allow the intended parents to attend appointments and delivery?
*
Yes
No
Some surrogates pump breast milk following the delivery and are compensated by the intended parents. Are you interested in pumping for your surrogate baby?
*
Yes
No
Some intended parents live far away from their surrogates. If your intended parents can’t see you regularly make it to appointments or delivery would that be okay with you?
*
Yes
No
Are you willing to come to the Los Angeles area for your OBGYN screening and preparation.*(Travel expenses will be reimbursed)
*
Yes
No
What is your occupation?
*
Describe your lifestyle, hobbies, etc.
*
Describe your home life
*
Are you a US citizen?
*
Yes
No
Do you have a valid drivers license?
*
Yes
No
Have you ever filed for bankruptcy?
*
Yes
No
Do you have a criminal history?
*
Yes
No
Have you ever been arrested? If so, explain
*
Do you have American Indian heritage?
*
Yes
No
Relationship status
*
Single
Relationship
Married
Divorced
Spouse/ partners name
*
First
Last
Spouse/ partners date of birth
*
mm/dd/yyyy
Does your partner have a history of substance abuse?
*
Yes
No
Does your partner have a history of psychiatric care?
*
Yes
No
Do you have a local support system?
*
Yes
No
Is there anyone in your support group that does not support your choice to become a Surrogate?
*
Yes
No
Who currently resides in your home?
*
How many sexual partners have you had in the last 6 months?
*
What compensation are you hoping for for your journey?
*
Describe why you are interested in becoming a Surrogate?
*
Submit
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