GBSEDS Surrogacy


Application



1. First Name:
 
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2. Last Name:
 
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3. Date of Birth:
 
   
4. What is your primary race/ethnic origin?
 
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5. Street Address: (Ex: 1234 Highland Dr.)
 
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6. City:
 
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7. State:
 
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Please explain "Other"
8. Zip Code:
 
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9. Phone Number:
 
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10. What is your contact preference?
 
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Please include time of day preference:
11. Your Height? (Ex: 5'7)
 
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12. Your Weight? (Ex: 145)
 
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13. Partners First and Last Name (Write "NA" if no partner/spouse):
 
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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 3 c-sections?
 
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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. Your partner/spouse's occupation (Write "NA" if no partner/spouse):
 
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25. What is your current relationship status?
 
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26. What is your highest level of education?
 
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27. Do you know if you are HepB immune? This vaccine is 3-4 injections spread out over several months with a blood test to confirm immunity.
 
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28. 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.
29. What type of birth control are you currently using?
 
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If not listed above, please note:
30. Please provide us pregnancy information.
 
Pregnancy # Personal Or Surrogacy Delivery Year/Month Delivery Type Gestational Age Birth Weight Gender(s) Complications
1:              
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5:              
31. Are you open to working with
 
Type Yes/No
International Intended Parents:  
Non-English speaking Intended Parents:  
32. What qualities would you consider most important when choosing Intended Parents to match with?
 
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33. How much communication would you like to have with your Intended Parent(s) after the birth on a scale of 1-10?
 
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34. Are you willing to provide breast milk service to the Intended Parents? You would be compensated $600/month (for a set period of time; for example, one to two months after delivery)
 
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35. Please describe the type of support you received from family and friends during your own pregnancies.
 
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36. What is the maximum number of embryos you are willing to have transferred to you?
 
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37. Are you willing to carry multiples (twins, triplets, etc.)?
 
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38. Are you open to selective reduction?
 
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39. If there is a medical problem with the pregnancy, or (for any physical or genetic abnormalities) with the child you are carrying as a surrogate and the Intended Parents want to consider termination, would you allow them to make that decision based on the advice of their physician and personal beliefs?
 
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Please Explain:
40. Please describe your character and personality.
 
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41. 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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42. Once you hit the submit button you will be taken to a page that allows you to enter the overall application. If your prescreen application was approved, you will automatically be able to log in and complete the overall application. Otherwise we are still evaluating your prescreen application.
 
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43. What is your email address for communication with you regarding your pre-screen application?
   
43. Please verify your email address
   
44. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
45. Verify your password
   


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

www.greatbeginningssurrogacy.com