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First name:
Your age: Weight:
Last name:
Height:
Street Address:
  
Ethnic background:
City:
  
State:
  
Zip:
Country:
  
Daytime phone:
  
Evening phone:
  
Email address:
  
Religious background:
 
Blood Type/ RH factor:
  
Did you attend College?:
  
Years attended:
Course of Study?:
  

Eye Color:

Complexion:
Hair Color:
Hair Texture:
Predominant Hand:
Physical Build:
High School G.P.A. __ College G.P.A. _____SAT Scores:
Date of your Last pap smear test?
Results?
Do you have any children:?
How Many:

 

Do any of the following conditions appy to you?

 
Have you ever been an Egg Donor before?
How many eggs were retrieved?
 
Are you willing to donate to a Gay couple?
I am willing to be an egg donor:  
Please indicate any health problems YOU have:
Family Health -- Please list your immediate family's Health problems
       
Egg Donor Application
The factors Surrogate Alternatives looks for when determining if a woman will be an acceptable Egg Donor for our program are as follows:
  • Must live in the state of California
  • Must be between the ages of 18-32
  • No history of genetic disorders or medical problems
  • Must have a flexible schedule
  • Must be willing to undergo a psychological evaluation and written test
  • No criminal history of any kind
  • Must be height/weight compatible
  • Must have a stable residence and not be planning to move out of the county in which the Egg Donor resides, from the time she submits her application.