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Featured Donor

Gestational Surrogate Application

Items with an * are required to submit your registration

Gestational Surrogates are needed to help Infertile Couples be Parents. You could earn $25,000 to $40,000 compensation!

Thank you for supplying information which may be sensitive. All information is strictly confidential.

Please call our Director of Surrogacy, Julie Allgood, with further questions, 818-326-7572.

Gestational Surrogate Requirements

*WOMEN ONLY

*Surrogates between the ages of 23-38

*Normal range for height and weight

*EXPERIENCED SURROGATES IN HIGH DEMAND

*Stay home or continue to work, your choice

*Must have at least 1 child of your own

*Non smoker/No drug use

*No criminal records- willing to do background check

*Dedicated and reliable for the process

*Referral Bonuses up to $1000

*Compensation for Surrogates starts at $25,000 up to $40,000 for experienced surrogates

General Information

First Name: *

Last Name: *

Age: *

Date of Birth: *

Address: *

City: *

State: *

Zip/Postal: *

Photo of yourself :

Please attach current headshot (or close-up) to facilitate application process.

Are you a U.S. citizen? : *

Contact Information

Email: *

Best Contact Phone # (cell, home, work?): *

Best time to reach you?: *

Physical Characteristics

Height: *

Weight: *

Race: *

Background

How did you hear about us? (Craigslist, Facebook, Google, Advertisement, etc.): *

(Please name the specific Search Engine if you found us on the internet.)

Occupation:

Do you have insurance? If so, who is your Provider?:

Married or Single? If single, are you in a steady relationship?: *

Are you sexually active?: *

Do you smoke? How much?: *

Do you drink alcohol? : *

Do you use drugs?: *

Are you currently taking any prescription medication? If so, what?: *

Number of pregnancies: *

Date of delivery(ies) (month & year)?: *

Number of children (must have 1 child or more): *

Number of miscarriages? : *

Have you or anyone in your household ever been arrested and/or convicted of a crime/misdemeanor/felony? : *

Yes

If yes, please give dates and explain. (Please note that it is standard practice for us to do background checks on all of our surrogates and their partners.):

Are you on any government assistance (food stamps, insurance)?: *

History

Any medical problems?: *

Yes

If yes, please list condition and any medications taken for treatment.:

Ever had surgery?: *

Yes

If yes, please list procedure and date performed.:

Have you had a tattoo in the past 12 months? : *

Yes

Have you ever been a surrogate before? What was the result?: *

Have you ever had an abnormal Pap Smear? If so, what was the outcome?: *

Have you ever had a sexually transmitted disease? If so, what was it and what was the outcome?: *

What was the first day of your last period?:

What type of contraceptives do you presently use? (If pills, please specify which kind you are taking.):

Are you immunized for Hepatitis B?:

Yes

How many babies are you willing to carry?:

If you are not currently registered with another agency are you willing to be exclusive to Alternative Conceptions for 6 months?:

Yes

Math Question: * 5 + 5 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

Call us at 310.954.1404

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