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Invitation to Apply

surrogate mother pregnancy

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
"I loved being a part of such a happy moment. The entire process was so incredible. This was a great experience!"

Tricia, California

* Required Fields
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) *  i.e. 5 feet 0 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. *

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Comments or Questions:
Referred by: *
If it was in a newspaper, magazine, website or other, please list the complete name:

Your Email *
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Retype Password *
Password Retrieval Question *
Password Retrieval Answer *
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•  For questions, call 1-800-SURROGATE (1-800-787-7642)

If you are not able to submit this form, please call: (818) 788-8288