APPLICATION FOR EMBRYO DONATION EMBRYOS ALIVE

Please provide the following contact information for applicant one
Please use the information for sperm donor and or egg donor:

Name

Street Address

City

State/Province

Zip/Postal Code

Home Phone

Cell Phone

Social Security Number

E-mail

Please	use egg information
Biological or Egg donor Applicant one	Biological Egg donor
Age at time of donation
Date of Birth
Marital status
Height
Weight
Hair Color
Eye Color
Health

Please provide the following contact information for Applicant 2:

Applicant 2

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

Please use donor information

Biological or sperm donor	Biological Sperm donor
Marital Status
Age at time of donation
Height
Weight
Hair Color
Eye Color
Health

Understanding of embryo Donation and adoption
briefly explain

Level of openness preference with adoptive family of embryos
Choose one of the following options:

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

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.

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)

Please refer to packet to go over the qualities in the adoptors you would choose.

ABOUT THE ADOPTOR/S YOU WOULD LIKE TO CHOOSE

Married Single Need a Surrogate

Age preference
Under 30 30 to 40 40 to 49 No preference Case By Case Basis

Note:
Regarding FDA or adoptor clinic requested additional bloodwork--
If your embryos were stored after May 2005 you may be required to obtain additional blood work and in some cases before May 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.

: Signature Signature
Date: Date

Embryos Alive LLC 7741 Pfeiffer Road Cincinnati, Ohio 45242 Office 513-793-1593 Fax: 513-793-0052 E-Mail bb@cinci.rr.com or Embryosalive@yahoo.com

Copyright © 2008 Embryos Alive. All rights reserved.
Revised: 05/01/08