Application for participation in surrogacy program in Ukraine by intended parents 

Legal Name:

Date of Birth: (DD/MM/YYYY)

*Email:

Phone: (H)

Phone: (W)

*Phone: (M)

Address:(Inc. Postal Code)

Marital Status:

Passport Number:

Ethnicity:

Do you have a valid Driver’s License?
YesNo

If yes, please advise the State of issuance and your Driver’s license Number:

Are you Currently Employed?
YesNo

What is your Employer’s name?

What is your current occupation?

What is your Monthly Income (after Deductions)?

Name:

Address:

(Inc. Postal Code)

Name:

Address:

(Inc. Postal Code)

Legal Name:

Date of Birth: (DD/MM/YYYY)

*Email:

Phone: (H)

Phone: (W)

*Phone: (M)

Address:(Inc. Postal Code)

Marital Status:

Passport Number:

Ethnicity:

Do you have a valid Driver’s License?
YesNo

If yes, please advise the State of issuance and your Driver’s license Number:

Are you Currently Employed?
YesNo

What is your Employer’s name?

What is your current occupation?

What is your Monthly Income (after Deductions)?

Relationship:

Phone:

Phone

Relationship:

Phone:

Phone

How long have you been in your current relationship?

What are your religious beliefs?

How active are you in faith or religious beliefs?

What are your family traditions for birthday and holidays?

What are your greatest passions in life?

What are your personal reasons for choosing Surrogacy to have a family?

How long have you been looking into Surrogacy as an option to create your family and when did you start looking for a Surrogate Mother?

What other agencies have you applied or worked with that provide Surrogacy related services?

What are your expectations in relation to the costs involved in Surrogacy? (including medical, legal and Surrogate expenses)

Have you ever used a Surrogate, Egg and/or Sperm Donor previously?
YesNo

Do you have Frozen Embryos?
YesNo

Do you require an Egg Donor?
YesNo

Do you require a Sperm Donor?
YesNo

If yes, please advise:

If yes, please advise:

Please provide your comments (if any):

Please provide your comments (if any):

Your comments or requests not listed above:

What attributes are you looking for in the Surrogate who will be assisting you through your Journey?

What is the earliest date that you would like to commence your first Transfer Cycle?

How do you envision your role and how heavily involved would you like to be during your Journey?

How much contact would you like to have with your Surrogate throughout your Journey?
DailyWeeklyBiweeklyMonthlyOther

What are your feelings about taking photos or filming from the onset of meeting your Surrogate until the Birth of your child(ren)?

How many Embryo Transfer Procedures would you be willing to undergo in order to conceive a child?
OneTwoThreeFourOther

Please provide your comments (if any):

Would you like to be present for the Embryo Transfer Procedure?
YesNo

Please provide your comments (if any):

What is the maximum number of Embryos you would like to use at each Transfer Procedure?
OneTwoThreeFourOther

If the first Embryo Transfer Procedure should fail, how soon would you want to start your second Transfer Cycle?

What is the maximum number of babies that you would feel comfortable with the Surrogate carrying? (Select all that apply)
SingletonTwinsTriplets

Would you consider asking the Surrogate to undergo a selective reduction in the event of a multiple pregnancy?

What are your views regarding abortion in the event that a baby is conceived and then determined by a Physician to have birth defects?

Would you like to be present for Obstetrical appointments?
YesNo

Please provide your comments (if any):

If your Doctor recommended an amniocentesis, how would you feel and would you want your Surrogate to consent to this testing?

What are your desires regarding being present during the birth of your child?

What are your feelings about taking photos or filming of the birth itself?

Would you like your Surrogate to pump Breast Milk for you?
YesNo

Please provide your comments (if any):

What are your plans for childcare after the Birth?

What amount of contact would you want with your Surrogate once your child(ren) has arrived?

When your child(ren) are older, what information do you plan on sharing with the child about your Journey?

What would be your response if your Surrogate expressed interest in wanting to meet or speak with your child(ren)?

What would be your response if your child(ren) expressed interest in wanting to meet or speak with your Surrogate?

If your Surrogate completes a successful Surrogacy for you, and you become a Parent, would you want a sibling for your child(ren)?
YesNoNot Sure at this time

If yes, would you like to have the same Surrogate for your second Surrogacy Journey?
YesNo

Please advise your comments (if any):

If you do not have a successful Surrogacy Journey, what are your plans for the future? (i.e. Adoption, Child Free Living)