Generation Next Fertility

 

Welcome to our Application!



1. Today's Date
 
   
2. Full Name
 
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3. State
 
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4. Primary Phone
 
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5. Email Address
 
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6. What is your age?
 
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7. Date of Birth
 
   
8. Closest description of your race. Note: Combinations of multi-racial descriptions are only in 1 menu. For example, "Black and Latin/Hispanic" is not listed in "Latin/Hispanic and Black" since they are the same.
 
If any descriptions include "Other", please explain.
9. What is your height?
 
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10. What is your current weight (in lbs.)? Note: just enter numbers ... example: 107
 
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11. Years completed of high school:
 
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12. Have you graduated from high school?
 
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13. Do you use nicotine products (i.e. cigarettes, e-cigarettes, nicotine gum, etc.)?
 
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If yes, how many do you use per week?
14. How many consecutive days have you spent in jail?
 
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15. Are you currently breastfeeding?
 
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16. Are you currently using any birth control?
 
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Please Specify Which Type
17. At what age did your menstrual periods begin?
 
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18. Are you adopted?
 
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19. How did you hear about this donor program?
 
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20. What is your email address for communication with you regarding your pre-screen application?
   
20. Please verify your email address
   
21. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
22. Verify your password