Application

1.

First Name: *

2.

Last Name: *

3.

Date of Birth? *

4.

What is your primary race/ethnic origin? *

5.

Street Address: (Ex: 1234 Highland Dr.) *

6.

City: *

7.

State: *

8.

Zip Code: *

9.

Phone Number: *

10.

What is your contact preference? *

11.

Your Height? (Ex: 5'7) *

12.

Your Weight? (Ex: 145) *

13.

Partners First and Last Name (Write "NA" if no partner/spouse): *

14.

Have you been a surrogate before? *

15.

What made you decide you wanted to become a surrogate? *

16.

Are you a US citizen or permanent resident? *

17.

Have you given birth to at least one child of your own? *

18.

Date of Most Recent Delivery *

19.

Have you had more than 5 pregnancies? *

20.

Have you had more than 3 c-sections? *

21.

Do you currently receive government assistance? *

22.

How did you hear about Great Beginnings? *

23.

Your occupation: *

24.

Your partner/spouse's occupation (Write "NA" if no partner/spouse): *

25.

What is your current relationship status? *

26.

What is your highest level of education? *

27.

Do you have medical testing results showing HepB immunity? This vaccine is 3-4 injections spread out over several months with a blood test to confirm immunity. *

28.

Have you traveled outside the US in the past 12 months? *

29.

What type of birth control are you currently using? *

30.

Please provide us pregnancy information. *

  Personal Or Surrogacy Delivery Year/Month Delivery Type Gestational Age Birth Weight Gender(s) Complications
1
2
3
4
5

31.

Are you open to working with *

  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? *

33.

How much communication would you like to have with your Intended Parent(s) after the birth on a scale of 1-10? *

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) *

35.

Please describe in detail the kind of support you will have for surrogacy from: 1) your partner/spouse, 2) children; 3) parents/siblings; 4) friends; 5) neighbors; and, 6) co-workers. *

36.

What is the maximum number of embryos you are willing to have transferred to you? *

37.

Are you willing to carry multiples (twins, triplets, etc.)? *

38.

Are you open to selective reduction? *

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? *

40.

Please describe your character and personality. *

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. *

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. *


What is your email address for communication with you regarding your pre-screen application?
(6-20 characters with 4 or more letters and 1 or more numbers)

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

www.greatbeginningssurrogacy.com