Intended Parent Application Form

Thank you for completing our Intended Parent Application. We look forward to speaking with you about it soon.

This application contains multiple sections and completing the entire form takes approximately 20 minutes. Please note that the application must be completed all at once and cannot be saved to finish later.

Thanks again for your interest in our program.

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Background Information - Step 1 of 4

Please answer the following questions with respect to Intended Parent 1.

Legal Name *

First

Last

Preferred Name/Nickname

Pronouns *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Date of Birth *

Place of Birth *

Social Security Number *

Citizenship status *

US citizen
US legal permanent resident
Other

County of citizenship *

Please specify: *

Length of residence in current state *

What languages do you speak? *

Religious Faith (if any) *

Have you been fully vaccinated for COVID-19? *

Do you have any children? *

Number of children *

Age(s) of children *

Marital Status *

Married
Engaged
Committed Relationship
Single/Divorced/Widowed
Separated

Legal Name of Spouse *

First

Last

Preferred Name/Nickname of Spouse

Pronouns *

Date of marriage *

Anticipated date of marriage *

Do you live together? *

Legal Name of Partner *

First

Last

Preferred Name/Nickname of Partner

Pronouns *

Do you live together? *

Do you have a separation agreement or a judgment of separation? *

Have you lived apart for at least 3 years? *

Are you employed? *

Name of Employer *

Position/Title *

Length of employment *

Annual income *

Have you ever had your wages garnished? *

Provide details *

Have you ever been involved in a bankruptcy? *

Provide details *

Have you ever had a foreclosure filed against you? *

Provide details *

Have you ever had an eviction action of any kind filed against you? *

Provide details *

Have you ever had a collection action filed against you? *

Provide details *

Are you pursuing your surrogacy journey with a spouse or partner? *

Please answer the following questions with respect to Intended Parent 2.

Legal Name *

First

Last

Preferred Name/Nickname

Pronouns *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Date of Birth *

Place of Birth *

Social Security Number *

Citizenship status *

US citizen
US legal permanent resident
Other

County of citizenship *

Please specify: *

Length of residence in current state *

What languages do you speak? *

Religious Faith (if any) *

Have you been fully vaccinated for COVID-19? *

Do you have any children? *

Number of children *

Age(s) of children *

Marital Status *

Married
Engaged
Committed Relationship
Single/Divorced/Widowed
Separated

Are you married to Intended Parent 1? *

Legal Name of Spouse *

First

Last

Preferred Name/Nickname of Spouse

Pronouns *

Date of marriage *

Are you engaged to Intended Parent 1? *

Legal Name of Fiancé *

First

Last

Preferred Name/Nickname of Fiancé

Pronouns *

Anticipated date of marriage *

Do you live together? *

Are you in a committed relationship with Intended Parent 1? *

Legal Name of Partner *

First

Last

Preferred Name/Nickname of Partner

Pronouns *

Do you live together? *

Do you have a separation agreement or a judgment of separation? *

Have you lived apart for at least 3 years? *

Are you employed? *

Name of Employer *

Position/Title *

Length of employment *

Annual income *

Have you ever had your wages garnished? *

Provide details *

Have you ever been involved in a bankruptcy? *

Provide details *

Have you ever had a foreclosure filed against you? *

Provide details *

Have you ever had an eviction action of any kind filed against you? *

Provide details *

Have you ever had a collection action filed against you? *

Provide details *

Please answer the following questions with respect to both Intended Parents jointly if there are 2 Intended Parents submitting this application.

Do you currently have medical insurance? *

Name of Insured *

Name of Insurance Company *

Policy Number *

Do you have a family plan or access to a family plan which will provide coverage for your child to be born via surrogacy? *

Total savings *

Under $50,000
$50,000-$75,000
$75,000-$100,000
$100,000-$125,000
$125,000-$150,000
$150,000-$200,000
$200,000+

How do you plan to fund your surrogacy journey? Check all that apply: *

Savings
Personal loan from a financial institution
Home equity loan
Borrow against retirement funds
Loan(s) from family or friends
Gift(s) from family or friends
Grants
Other

Please specify *

Please provide documentation supporting your selected method(s) of funding your surrogacy journey. *

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

Have you ever worked with another surrogacy agency? *

Which agency? *

Are you currently working with that agency? *

Why did you stop working with that agency? *

When did you stop working with that agency? *

Do you plan to work with more than one surrogacy agency simultaneously? *

Which agency? *

Have you ever undergone a psychological screening before associated with assisted reproduction or surrogacy? *

Name of mental health provider: *

Address of mental health provider: *

Address Line 1

Address Line 2

City

State

Zip Code

Phone number of mental health provider: *

Would you be willing to sign a release for NYSC to communicate with the mental health provider and obtain a copy of the evaluation/report? *

Are you willing to undergo a psychological screening as part of your surrogacy journey with NYSC? *

Do you have an attorney selected to assist you with your surrogacy journey? *

Name of attorney *

Address of attorney *

Address Line 1

Address Line 2

City

State

Zip Code

Phone number of attorney *

Email address of attorney *

Are you currently working with a fertility clinic? *

Name of fertility clinic *

Address of fertility clinic *

Address Line 1

Address Line 2

City

State

Zip Code

Phone number of fertility clinic *

Name of your Reproductive Endocrinologist *

Name of surrogacy coordinator *

Email address of surrogacy coordinator *

Do you plan to use this fertility clinic for your surrogacy journey? *

Do you know what fertility clinic you will use for your surrogacy journey? *

Name of fertility clinic *

Address of fertility clinic *

Address Line 1

Address Line 2

City

State

Zip Code

Phone number of fertility clinic *

Name of your Reproductive Endocrinologist *

Name of surrogacy coordinator *

Email address of surrogacy coordinator *

Do you currently have embryos available for surrogacy? *

How many embryos do you have? *

What day were your embryos frozen? (ex. Day 5, not the calendar date) *

Have you genetically tested your embryos? *

What type of testing did you use? *

PGS/PGT-A
PGS/PGT-SR
PGD/PGT-M

Are any of them mosaic? *

Do you plan to use your mosaic embryos for surrogacy? *

Where are your embryos currently located? *

What is the source of the sperm used to create your embryos? *

Intended Parent 1
Intended Parent 2
Intended Parents 1 & 2
Known Sperm Donor
Anonymous Sperm Donor
Known Embryo Donor(s)
Anonymous Embryo Donor(s)

Please check any of the following that Intended Parent 1 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 1 or their biological family: *

Please check any of the following that Intended Parent 2 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 2 or their biological family: *

Please check any of the following that Intended Parent 1 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 1 or their biological family: *

Please check any of the following that Intended Parent 2 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 2 or their biological family: *

Name of Known Sperm Donor: *

First

Last

Relationship to Intended Parent(s): *

Name(s) of Known Embryo Donor(s): *

Relationship to Intended Parent(s): *

Did the Known Embryos Donors use donor gametes to create the embryos? *

Yes – donated eggs
Yes – donated sperm
Yes – donated eggs and sperm
No

Current location of Donated Embryos: *

What is the source of the egg used to create your embryos? *

Intended Parent 1
Intended Parent 2
Intended Parents 1 & 2
Known Donor
Anonymous Donor
Known Embryo Donor(s)
Anonymous Embryo Donor(s)

Please check any of the following that Intended Parent 1 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 1 or their biological family: *

Please check any of the following that Intended Parent 2 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 2 or their biological family: *

Please check any of the following that Intended Parent 1 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 1 or their biological family: *

Please check any of the following that Intended Parent 2 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 2 or their biological family: *

Do you plan to use donated embryos? *

Do you plan to use known or anonymous embryo donor(s)? *

Known
Anonymous

Current status of donation process: *

Do you need NYSC to help you obtain donated embryos? *

What source of sperm do you intend to use to create your embryos? *

Intended Parent 1
Intended Parent 2
Intended Parents 1 & 2
Known Donor
Anonymous Donor

Please check any of the following that Intended Parent 1 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 1 or their biological family: *

Has the sperm been deposited and tested yet? *

When did that happen? *

Please check any of the following that Intended Parent 2 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 2 or their biological family: *

Has the sperm been deposited and tested yet? *

When did that happen? *

Please check any of the following that Intended Parent 1 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 1 or their biological family: *

Has the sperm been deposited and tested yet? *

When did that happen? *

Please check any of the following that Intended Parent 2 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 2 or their biological family: *

Has the sperm been deposited and tested yet? *

When did that happen? *

Name of Known Donor *

First

Last

Relationship to Intended Parent(s): *

Current status of donation process *

Do you need assistance from NYSC in obtaining donated sperm? *

What source of eggs do you intend to use to create your embryos? *

Intended Parent 1
Intended Parent 2
Intended Parents 1 & 2
Known Donor
Anonymous Donor

Please check any of the following that Intended Parent 1 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 1 or their biological family: *

Have the eggs been retrieved yet? *

Please check any of the following that Intended Parent 2 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 2 or their biological family: *

Has the eggs been retrieved yet? *

Please check any of the following that Intended Parent 1 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 1 or their biological family: *

Has the eggs been retrieved yet? *

Please check any of the following that Intended Parent 2 has been diagnosed with: *

HIV
STDs or STIs
Genital ulcerative lesions
Herpes simplex
Chancroid
Urethral discharge
Syphilis
Perianal condylomata
Percutaneous drug use (i.e., track marks)
Tattoo or piercing infections
Disseminated lymphadenopathy
Oral thrush
Kaposi sarcoma
Jaundice, hepatomegaly or icterus
Smallpox
Vaccinia necrosum
Vaccinial keratitis
None of the above

Please specify any hereditary and/or genetic medical issues for Intended Parent 2 or their biological family: *

Has the eggs been retrieved yet? *

Name of Known Donor *

First

Last

Relationship to Intended Parent(s): *

Current status of donation process *

Do you need assistance from NYSC in obtaining donated eggs? *

Do you plan to genetically test your embryos once they are created? *

How many embryo transfer procedures will you be willing to undertake with your surrogate to achieve a pregnancy? *

Do you plan to select the sex of the embryos you transfer? *

Are you still attempting to achieve a pregnancy to be carried by Intended Parent 1 or 2? *

Why are you pursuing surrogacy? *

Please share some information you would like potential surrogates to know about you when considering a match (this will be used in your profile): *

Have you ever used a surrogate before? *

Please describe your experience: *

Describe your ideal surrogate: *

Describe the relationship you would like with your surrogate during the process/pregnancy: *

Describe the relationship (if any) you would like with your surrogate after delivery: *

For each of the following matching criteria, please indicate if you have a preference or do not have a preference. If you have a preference, please describe what your preference is. The more details you provide to us, the better.

Age *

Preference
No Preference

Please describe Preference *

Marital Status *

Preference
No Preference

Please describe Preference *

Number of Children *

Preference
No Preference

Please describe Preference *

Race *

Preference
No Preference

Please describe Preference *

Religion *

Preference
No Preference

Please describe Preference *

Sexual Orientation *

Preference
No Preference

Please describe Preference *

Gender Identity *

Preference
No Preference

Please describe Preference *

Employment/Type of Employment *

Preference
No Preference

Please describe Preference *

Location *

Preference
No Preference

Please describe Preference *

Surrogacy Friendly Insurance *

Preference
No Preference

Please describe Preference *

Experienced Carrier (previously acted as surrogate) *

Preference
No Preference

Please describe Preference *

Recreational Use of Marijuana while NOT Pregnant *

Preference
No Preference

Please describe Preference *

Willing to do a Double Embryo Transfer due to low quality embryos *

Preference
No Preference

Please describe Preference *

Willing to do a Double Embryo Transfer to try to for twins *

Preference
No Preference

Please describe Preference *

Willing to Pump Breast Milk *

Preference
No Preference

Please describe Preference *

Willing to Act as Your Surrogate Again in the Future *

Preference
No Preference

Please describe Preference *

COVID-19 Vaccination Status *

Preference
No Preference

Please describe Preference *

Do you have any other matching criteria? *

Do you want to attend the surrogate’s medical appointments during the screening process and embryo transfer? *

Do you want to attend the surrogate’s medical appointments during the pregnancy? *

Do you want to be in the delivery room when your child is born? *

Do you want to visit your surrogate in her home? *

Yes
No
Maybe

Do you want the surrogate to visit you in your home? *

Yes
No
Maybe

Under which of the following circumstances would you want your surrogate to be willing to terminate the pregnancy (check all that apply): *

Unlikely that pregnancy will be successful
Unlikely that child will be born alive
Unlikely that child would survive for a substantial period after birth
Child will have severe physical disabilities which would negatively impact his/her quality of life
Child will have severe physical deformities which would negatively impact his/her quality of life
Child will have severe mental or intellectual disabilities which would negatively impact his/her quality of life
None of the above

Under which of the following circumstances would you want your surrogate to selectively reduce multiples even if all babies could be born healthy? (check all that apply): *

Reduce twins to singleton
Reduce triplets or more to twins
Reduce triplets or more to singleton
None of the above

Would you be willing to work with a surrogate who would want to selectively reduce multiples in the following circumstances even if all babies could be born healthy? (check all that apply): *

Reduce twins to singleton
Reduce triplets or more to twins
Reduce triplets or more to singleton
None of the above

Is all of the information contained in this application true and accurate to the best of your knowledge? *

Do you agree to notify NYSC immediately if any of the information contained in this application becomes incorrect or incomplete? *

Do you understand that the information contained in this application will be used by NYSC in determining whether you meet the eligibility requirements to act as an intended parent? *

Do you understand that the information contained in this application will be used by NYSC for purposes of screening potential surrogates and matching you with a Surrogate(s) that is a good fit for you? *

Do you authorize NYSC to provide this application, the information contained herein and the documents submitted in support of this application, to third parties as necessary to facilitate the surrogacy process including, but not limited to, the fertility clinic, any medical and/or psychological evaluators, insurance agents, escrow agents and/or attorneys for the parties? *

Do you authorize NYSC to share the information contained in this application (with the exception of financial information, social security numbers and contact information) with potential surrogates as part of the matching process? *