Application Form Name & Surname *Date of Birth *Height (Feet) *Weight (lbs) *Hair Color *Eye Color *Upload photo's of yourself (Maximum 5 Images - 3 MB limit per image) *Drag and Drop (or) Choose FilesEmail Address *Ethnic Origin *Maternal Heritage *Paternal Heritage *Blood Type *Click to chooseA PositiveA NegativeB PositiveB NegativeAB PositiveAB NegativeO PositiveO NegativeHighest Level of Education *University Name *Name of your Degree *Do you have any artistic abilities? *Click to chooseYesNoList of abilities *Do you have any athletic abilities? *Click to chooseYesNoList of athletic abilities? *What is your current occupation? *Please describe your personality *Do you wear or have you worn eyeglasses? *Click to chooseNoYesHave you worn braces? *Click to chooseYesNoAt what age did you start wearing them? *Why do you want to become a donor? *Being a donor is a big responsibility. It requires going to several doctor's appointments, taking injections and having minor out-patient surgery. Do you feel prepared to commit to this process? *Click to chooseYesNoI'm not sureAre you open to being matched with all types of families regardless of sexual preference, marital status, ethnicity or sex of the egg recipient? *Click to chooseYesNoPlease explain why *If they request it, are you willing to meet your intended parents? *Click to chooseYesNoAre you open to meeting the child in the future if that is requested? *Click to chooseYesNoAre you open to exchanging future contact information with your intended Parents(s)? *Click to chooseYesNoWhere did you grow up? *Do you have any siblings? *Click to chooseYesNoTell us about them *Do you have any children? *Click to chooseYesNoTell us about them *Personal Health HistoryAny past or current medical problems (including surgeries, accidents, birth defects, depression, etc.)? *Click to chooseYesNoList your medical problems *Do you drink alcohol? *Click to chooseYesNoHow many drinks per week? *Have you ever been pregnant? *Click to chooseYesNoHow many times and what was the outcome? *Have you ever been a donor before? *Click to chooseYesNoDid a pregnancy occur? *Click to chooseYesNoAre you currently taking any medication (for physical or mental health)? *Click to chooseYesNoWhat medications are you on and why? *Are you taking any recreational drugs *Click to chooseYesNoWhat are you taking? *Do you smoke? *Click to chooseYesNoAre your menstrual cycles regular? *Click to chooseYesNoPlease explain why *Family Medical History Note: Medical history will be verified. Anything purposefully omitted may result in being dropped from the program. The following members need to be in your list. Father Mother Paternal Grandmother Paternal Grandfater Maternal Grandmother Maternal Grandfather Siblings List family medical historyBiological Family Member *Sex *Click to chooseMaleFemaleAge *Height (Feet) *Eye Color *Hair Color *Education Level *Deceased *Click to chooseYesNoOccupation *Add itemRemove itemDiseases & Medical ConditionsCancer *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Mental Retardation *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Autism / Asperger's *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Physical Malformation *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Paralysis or crippling disorders *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Alcohol or Drug Addiction *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Cystic Fibrosis *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Sickle Cell Anemia *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Lupus *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Miscarriages, still births, neonatal deaths *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *High blood pressure, heart attacks or strokes *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Memory loss or dementia *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Osteoporosis *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Arthritis *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Allergies *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Blood diseases *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Diabetes (Specifically Type 1 or Type 2) *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Thyroid issues *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Learning disabilities *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Seizure or epilepsy *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Depression *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Panic attacks *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Schizophrenia *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Bipolar Disorder *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *ADD or ADHD *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Age-related issues *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Kidney problems / diseases *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Reproductive problems: i.e. endometriosis, hysterectomies, late-term miscarriages, etc *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Vision/Sight/Eye Problems *Click to chooseYesNoPlease explain to whom, have they passed away (please include age), what was the age of onset/medication *Send Message
