Application - Simple Surrogacy

Initial Surrogate Application

Please provide your name, email and password to create a profile.

You will use this profile to complete your application.

First Name:

Last Name:

Email:

Confirm Email:

Your email address will serve as your username to log into our site.

Password:

Confirm Password:

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Surrogate Login
Intended Parent Login

Login as a Surrogate

Login as an Intended Parent

Egg Donor's Login
Donations - Intended Parent Login

In order to be qualified to work with our agency as a Surrogate, you must:
	Be a citizen or permanent resident of the United States
	Be between the ages of 21-40 (Traditional Surrogates must be under 35)
	Have given birth to a child of your own
	Have had uncomplicated pregnancies and deliveries
	Be height-weight proportionate (BMI must be 33 or lower)
	Must have a valid driver's license
	Have experienced a full-term pregnancy and delivery
	Be in a stable living situation (7 year address verification is completed on all Surrogates)
	Have the support of your spouse or partner (when applicable)
	Be willing to review your Surrogacy Agreement with a licensed attorney (at IP's expense)
	Be willing to adhere to all contractual obligations throughout the process
	Not be on public assistance
	Be able to pass a background check (no felony convictions)
	Have read and understand the Surrogacy process, by clicking on the link to the left
	Be willing to take medications via injection (when instructed by RE)
	Not smoke, take illegal drugs, or be exposed to second hand smoke
	Be willing to take refrain from alcohol throughout the medical process and pregnancy
	Not have any sexually transmitted diseases that would subject you or the child you are carrying to physical harm
	Not have any psychiatric illnesses or take medications for depression or anxiety
	Have reliable transportation to travel to the Doctor's appointments and screening or matching appointments
	Not have had any tattoos or piercings within the past 12 months
	Be able to provide contact information for past OBs or family doctors so we are able to obtain medical records
	Sign necessary forms (HIPPA or medical release) to allow us access to Medical records from previous pregnancies, and surrogacy journeys
	Enjoy pregnancy and be motivated by the wish to help others create or add to their family
	Not have traveled to any countries in the past 6 months where there is an active Zika Virus transmission, including Brazil, The Carribbean, Mexico or Cape Verde, Africa
	Date of Birth:

Surrogates

Initial Surrogate Application

Login as a Surrogate

Login as an Intended Parent

Login as a Donor

Donations - Login as an Intended Parent

Login Information
Please provide your name, email and password to create a profile. You will use this profile to complete your application.
First Name:	Last Name:

Email:	Confirm Email:

Your email address will serve as your username to log into our site.
Password:	Confirm Password:

Choose a password 6-12 characters in length. Your password is case sensitive.
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