ONLINE APPLICATION FOR EMBRYO DONATION
EMBRYOS ALIVE

APPLICANT 1 FEMALE

Name
Street Address
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
Cell Phone
Social Security Number
E-mail

Marital Status:

Married Engaged Living together Other Single Divorced Widow Widower

Choose one of the following options:

Biological
Egg Donor

Please Describe Egg Donor:

Date of Birth
Age of Time of Donation
Height
Weight
Hair Color	Blonde Brown Black Red Gray White
Eye Color	Blue Brown Black Green Gray Violet

Ethnic Background select all that apply:

Various European
Asian
African American
Don't Know
Caucasian
Will Obtain
Other

 Ethnic Background Female

Hobbies and Interests

Career/Occupation

Health:

Excellent Good Fair
Poor  Other (please explain)

Comments:

Please provide the following contact information for
Applicant 2 Male:

Male  Name
Street Address
City
State/Province
Zip/Postal Code
Country
Cell Phone
Work Phone
Home Phone
FAX
Social Security Number
E-mail

Biological or sperm donor:

Biological
Sperm Donor

Date of Birth
Age At Time of Donation
Height
Weight
Hair Color	Blonde Other Brown Black Red Gray White
Eye Color	Blue Other Brown Black Green Gray Violet

Ethnic Background:

Various European
African American
Asian
Caucasian
Hispanic
Don't know
Other

Ethnic Background

Hobbies/Interests

Career/Occupation

Health Male

Excellent
Good
Fair
Poor
Other (please explain)

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HOW quickly do you want to go in the process?

As Quickly As Possible A Year Would Be Great Just Getting Started We Are Currently Pregnant So After Birth (due date)

Other/Comments

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HOW Did You Hear about e.a.?

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Understanding of embryo Donation and adoption briefly explain

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about the embryos

Number of Embryos to Donate

Number of Cells

2 PN 3 Day Blast 5 Day Blast 7 Day Blast Not Sure Other

Year They Were Stored:

Quality or Grade (if known)

Adoption preferences About the adoptors you would like to choose

Choose From The Following Options:

Married
Single
Either Married or Single
Someone Who Needs A Surrogate To Carry

Comments

Age Preference of Adoptors:

Under 30
30-40
40-49
Under 65
No Preference
Case By Case Basis

Select any of the following options that apply:

Case By Case Basis
Prefer Someone With No Children
1
More than 1 if they are Adopted
2
3
4
5
6
No Preference

Adoptors religion and level of importance:

Christian
Catholic
Jewish
Non-Christian
Muslim
Hindu
Buddhist
Other

Choose one of the following options:

Regular Attenders Pentecostal-Spirit Filled Non practicing Not important Other See comments

Comments

Can The Adoptors Be From Another Country?

Level Of Openness Preference With Adoptive Family of Embryos:

Will let the adoptors decide After 18 E-Mail Only Agency Liason Closed/Anonymous Case By Case Not Sure Open for Medical Reasons Only Other (please explain)

Although we cannot guarantee your anonymity although procedures and thorough measures are taken to protect your identity whenever requested
Visit www.embryosalive.com for pros and cons of the levels of eligibility.

 

 Note: Regarding FDA or clinic bloodwork--
If your embryos were stored after May 25, 2005 you may be required to obtain additional blood work
and in some cases before May 25, 2005. Although you as a Donor  do not pay any fees, the adopters may
be required to have you obtain additional blood work and that additional blood work can cost adoptors
between $300.00 to $800.00 per person if not covered by your insurance-
adoptors really appreciate it if you can use your insurance and they are happy to pay your insurance co-pay as applicable.

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Please send pictures! Adoptors like to see what the baby/s will look like!

Signature

Date

Signature 2