GBSEDS Surrogacy


Application



1. Maiden name
 
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2. First Name:
 
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3. Last Name:
 
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4. Date of Birth:
 
   
5. What is your primary race/ethnic origin?
 
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6. City:
 
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7. State:
 
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Please explain "Other"
8. Phone Number:
 
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9. What is your contact preference?
 
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Please include time of day preference:
10. Your Height? (Ex: 5'7")
 
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11. Your Weight? (Ex: 145)
 
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12. What is your current relationship status?
 
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13. Date of most recent piercing (enter month, day and the year 1960 if you do not have any piercings)
 
   
14. Have you been a surrogate before?
 
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15. What made you decide you wanted to become a surrogate?
 
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16. Are you a US citizen or permanent resident?
 
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17. Have you given birth to at least one child of your own?
 
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18. Date of Most Recent Delivery
 
   
Please include Gestational Age, e.g., 38w3d
19. Have you had more than 5 pregnancies?
 
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If yes, please explain
20. Have you had more than 1 c-section?
 
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If yes, please explain
21. Do you currently receive government assistance?
 
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If yes, what type? (Ex: Insurance, Food Stamps, Cash Aid)
22. How did you hear about Great Beginnings?
 
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Please describe in detail friend/family referral, including, name, relationship, etc.
23. Your occupation:
 
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24. What is your highest level of education?
 
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25. Have you traveled outside the US in the past 12 months?
 
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If Yes, please indicate where, when and how long for each trip outside the US in the last 12 months.
26. What type of birth control are you currently using?
 
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If not listed above, please note:
27. Are you open to working with International Intended Parents?
 
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If no, please explain
28. Are you open to working with Non-English Speaking Intended Parents?
 
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If no, please explain
29. Are you willing to carry multiples (twins, triplets, etc.)?
 
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30. The next questions will be used to establish your username and password to be able to complete the overall application if your prescreen is approved.
 
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31. Once you hit the submit button you will be taken to a page that will provide you with your initial surrogacy assessment! If your prescreen application is approved, you will automatically be able to log in and complete the overall application if you wish. Otherwise, we will contact you to discuss your results
 
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32. What is your email address for communication with you regarding your pre-screen application?
   
32. Please verify your email address
   
33. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
34. Verify your password
   


4225 Executive Square, Suite 600, La Jolla, CA 92037 Phone 858-732-4277 (GBSS)  Fax 858-754-1225

www.greatbeginningssurrogacy.com