Surrogate Mother Application
 

Welcome to CSP

Please complete the surrogate mother registration page

For more information before registering: Click Here
If you have already registered with CSP: Click Here

Surrogate Mother Basic requirements:
  • Permanent resident (i.e. have a green card) and currently live in the U.S.A.
  • Be a non-smoker
  • Between 21 and 42 years of age (flexible for repeat Surrogate Mothers)
  • Not be on any form of government assistance for yourself
  • Have already given birth to a child that you are currently raising
* Please Note: Due to unfavorable laws regarding surrogacy, we are unable to work with women who reside in the following states:  AK, AL, AZ, DC, HI, IA, ID, IN, LA, MI, MO, MS, MT, ND, NE, NH, NJ, NM, NY, OK, RI, SC, SD, WA, WY
* Required Fields
Date:
Your First Name: *
Your Last Name : *
Your Date of Birth (mm/dd/yyyy): *
Street Address: *
City: *
State : *  
Zip Code: *
Home Phone: *   
Work Phone:   
Cellular Phone:   
Number of children: *   Ages:*
Have you ever had a C-section? *   If Yes, how many? 
For any pregnancy, did you deliver before 37 weeks? *
If Yes, please explain in detail *
Your Height: *  feet       inch(es)
Your Weight: *  lbs. 
Do you smoke or use tobacco? *
Are you currently taking any medications? *
If yes, list medications
Reason for medication:
Do you currently have health insurance? *
Do you currently have maternity coverage? *
Do you or any member of your family receive government assistance? (If you receive WIC or assistance for foster children answer "No" to this question) *
Have you ever been arrested or had any troubles with the law including DUI? *
If Yes, please explain:
Have you ever been a surrogate mother before? *
I acknowledge that I must deliver at a hospital with a certified obstetrician. *
Best time to reach you:
Comments or Questions:
Referred by: *
If it was in a newspaper, magazine, website or other,
please list the complete name:

Your Email *
Retype Email *
Create a Password *
(you will be able to log in once we enroll you into our program)

(4-10 characters; case sensitive)
Retype Password *
Password Retrieval Question*
Password Retrieval Answer*
(Ten-character maximum; not case sensitive)
Do you wish to receive text messages from CSP? (You can opt out at anytime)
 

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::  Having trouble signing in?
::  I have a question before registering.
::  For questions, call 1-800-SURROGATE (1-800-787-7642)
                             

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