Become A surrogate Mother | Gestational Carrier Registration

Dear Gestational Carrier,

To be considered as a gestational carrier for our program, please read the following and complete initial registration form. We will contact you as soon as possible and inform you of the next steps. If you have any questions, please don’t hesitate to contact us.

In order to qualify with our agency as a gestational carrier, you must:

Be between the ages of 21 and 42
Live in the United States and be either a legal permanent resident or a US Citizen
Be Height and weight appropriate (BMI below 32) Compute BMI
Have experienced a full-term pregnancy and delivery at least once
Have raised and lived with at least one child
Have never been convicted of a felony
Not presently smoke
Not take any illegal drugs
Never been treated for drug or alcohol abuse
Be willing to refrain from alcohol throughout the medical process and pregnancy
Not have any sexually transmitted diseases that would put at risk you or the child you are carrying to a physical harm
Not be on any psychiatric medications or posses any psychiatric illnesses
Live in a stable home environment
Not be on public assistance
Be willing to go through and pass the background check
Not have any tattoos or piercing done in the last 12 months
Be able to provide medical records from previous deliveries with contact info of all prior OBGYN
Be willing to take all necessary injections or medications prescribed by a fertility specialist or an OBGYN during your surrogacy process
Be willing to adhere to all contractual obligations as a surrogate
Have a driver’s license and a reliable transportation
Understand that you cannot move to another state during your surrogacy process
Understand that this process is very serious and Intended parents are relying on you being honest, trustworthy, mature and committed to comply with all instructions
Enjoy being pregnant and willing to help others create their own family

* I agree to all of the above

Please check your body mass index (BMI) first.

Your BMI should be more than 15 and less then 32

My height:*

My weight:*

Compute BMI

First Name:*

Middle Name:

Last Name: *

Maiden Name:

Date of Birth
(mm/dd/yy):*

Mailing Address:

Street: *

City: *

State: *

Country: *

Zip/Postal code:

Cell Phone: *

OK to leave message ?

YesNo

Home Phone:

OK to leave message ?

YesNo

Work Phone:

OK to leave message ?

YesNo

Your Email: *

Create Password: *

Note, You will use your Email to login

Password has to have at least six characters and include at least one number

Verify Created Password: *

Fields marked with an asterisk (*) are required.

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was awarded to Robert G. Edwards "for the development of in vitro fertilization"

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Note, You will use your Email to login

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