ONLINE APPLICATION FOR EMBRYO DONATION
EMBRYOS ALIVE

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Thank you for choosing Embryos Alive to assist with your donation.
To assist you in finding the right family for your embies please provide the following information:

Applicant one (Female)
Please use the information for sperm donor and or egg donor:

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

Please	use egg information
Biological or Egg donor	Biological         Egg donor
Age (at time of donation)	Date of Birth
Marital status	Married Seperated Divorced Other
Height	Weight
Hair Color	Blonde Brown Black Red Gray White Receding    Eye Color   Blue Brown Black Green Gray Violet Hazel
Ethnic Background	Various European Asian Hispanic African American Other Caucasian Don't know Will obtain   More specifically- Example: German, Irish, Portuguese
Hobbies Interests
Career/Occupation
Health	Excellent Good Fair Poor See comments   Comments

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Please provide the following contact information for Applicant 2:
Applicant 2 Male

Name Applicant 2
Social Security Number
Street Address (if different   than spouse)
City
State/Province	Zip Code
Home Phone
Cell Phone
E-mail

Please use sperm donor information

Biological or sperm donor	Biological         Sperm donor
Marital Status
Age at time of donation	Date of Birth
Height	Weight
Hair Color	Blonde Brown Black Red Gray White Receding     Eye color      Blue Hazel Brown Black Green Gray Violet
Ethnic Background	Various European Asian Hispanic African American Caucasian Don't Know from Canada Italian Bi/racial English Irish India Will obtain Other   More specifically- Example: Irish, German, Scandinavian, Portuguese, etc.
Hobbies Interests
Career/Occupation
Health	Excellent Good Fair Poor See comments Comments

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HOW quickly do you want to go in the process?

 As quickly as possible                         Just getting started                                 
 A year would be great                         We are currently pregnant so after birth (due date)

Other/Comments:

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HOW Did You Hear about e.a.?

My Doctor or Clinic Google Yahoo cyber friend cyber list/group News show Referred by NEDC News paper article Blog Embryo Adoption Book or Journal article Other

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Understanding of embryo Donation and adoption briefly explain

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about the embryos

  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Other   Number of Embryos to Donate      2 PN 3 day Blast Not Sure Other   Number of Cells        2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 Not sure   Year they were stored

Quality or grade (if known)

Please request the form from your clinic so they can send you a copy of your embryology results, blood lab results (and if you used an egg or sperm donor please request their summary called "letter of eligibility")
Pictures are always requested! Identifying information will be blacked out.

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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 60 No Preference  Case By Case Basis

Number of Children Adoptors Could Have   Case By Case Basis Prefer someone with no children 1 More than 1 if they are Adopted or older children 2 3 4 5 No Preferecnce  
                         Note: Some families have step children, his children from another marriage, her children from another marriage, older children, and/or adopted children.

Adoptors religion and level of importance
Other Catholic Christian Jewish Non-Christian Muslim Hindu Budhist                          Other see comments Pentecostal-spirit filled Regular Attenders Not practicing Not important

Comments

Can the adoptors be from a foreign country?   Yes    No      Case By Case Basis

Please explain briefly your understanding of Open/E-Mail/Agency/ Liaison/ or Closed preference

Level of openness preference with adoptive family of embryos

Choose from the following options Will let the adoptors decide After 18 Open E-Mail Only Agency Liasion Closed/Anonymous Case By Case Basis Not Sure

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 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 just pay your co-pay.

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

 

                                                   

Signature                Signature 

               Date:                                  Date

                                 Please print and mail or fax
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