Surrogate Application

Congratulations! You are taking the first step in the surrogacy process to become a surrogate with Pathways To Parenthood Surrogacy Agency. Once you complete and submit your application, you are one step closer to helping a family realize their dream of having a baby.

Before completing the application, be sure you meet the basic criteria necessary to pass the medical screening requirements set by fertility clinics. Not sure? We are happy to help!

Contact us with your questions. Please provide as much information as possible about your history that you would like feedback about.

Nota: No podemos aceptar la forma con respuestas en Español. Debe enviar la forma en Inglés. Además, solo podemos aceptar solicitudes de ciudadanos de los Estados Unidos.

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Name*

Email Address*

Mobile Phone Number*

Preferred Method of Communication*

What is your nearest major city?*

Home Address*

Date of Birth*

Are you a U.S. Citizen?*

Why do you want to become a surrogate?*

Have you applied as a surrogate with any other agencies?*

For the following questions, please rank what is most important to you on a scale of 1 to 5.

On this scale, 1 is the most important factor, and 5 is the least important.

Location of Agency*

How important is the agency location (from 1 to 5)?

Please enter a number from 1 to 5.

Compensation*

How important is your compensation (from 1 to 5)?

Please enter a number from 1 to 5.

Time to match with intended parents*

How important is time to match with intended parents (from 1 to 5)?

Please enter a number from 1 to 5.

Location of intended parents and/or fertility clinic*

How important is the location of the intended parents and/or fertility clinic (from 1 to 5)?

Please enter a number from 1 to 5.

Support group with current/past surrogates*

How important is access to a support group with current/past surrogates (from 1 to 5)?

Please enter a number from 1 to 5.

What is your height?*

What is your current weight?*

Are you trying to gain/lose weight?*

Do you smoke?*

Are you around secondhand smoke?*

Do you use cannabis products?*

Have you had any tattoos or piercings in the last 6 months?*

How many pregnancies have you had?*

Do you have children?*

How many children do you have?*

If so, what are their ages?

Did you have any complications/receive any diagnoses during your pregnancies or births? If yes, please explain.

Are you currently breastfeeding? If yes, when do you plan to stop breastfeeding? If you are breastfeeding currently, are you having regular periods?

Have you ever been convicted of a crime?*

If yes, please explain.

Are you taking any medications?*

If yes, list medications, what they are prescribed for, and how long you have been taking them.

Are you receiving any of the following forms of government assistance? Check all that apply.*

Food Stamps

Medicaid

Cash Assistance / Welfare

WIC

SSI

Public Housing / Section 8

Government Subsidized Childcare

Other (Please Specify)

None of the above

Do you or your partner/spouse have any past or current or ongoing cases with Child Protective Services?*

What is your readiness to begin the surrogacy process?*

Would you be interested in speaking with an experienced surrogate mother about the surrogacy process and her surrogacy journey?*

How did you hear about Pathways To Parenthood Surrogacy Agency?*

Nota: No podemos aceptar la forma con respuestas en Español. Debe enviar la forma en Inglés. Además, solo podemos aceptar solicitudes de ciudadanos de los Estados Unidos.

The submit button will appear once you make a selection:*

Unfortunately, we cannot assist potential surrogates or parents living outside of the United States.

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