Egg Donor Application Personal information Name (First, Middle, Last): Date of birth Age Address Street Address Street Address Line 2 City State Zip Code Contact information Email Phone Others Height Weight Eye Color Hair Color Ethnic origin Ethnic of mother Ethnic of father Highest Level of education and Major Blood Type Current living country What is your current occupation? Do you wear or have you worn eyeglasses? Have you worn braces? Where did you grow up? Marital Status Describe your personalities Why do you want to become a donor? Being a donor is a big responsibility. It requires going to several doctor's appointments, taking injections and hav-ing minor out-patient surgery. Do you feel prepared to commit to this process? Yes No Are you open to being matched with all types of families regardless of sexual preference, marital status, ethnicity or sex of the egg recipient? Yes No If they request it, are you willing to meet your intended parents? Yes No Are you open to meeting the child in the future if that is requested? Yes No Are you open to exchanging future contact information with your intended Parents(s)? Yes No Do you have any siblings? If so, tell us about each of them: Yes No Do you have any children? If so, tell us about each of them: Yes No Medical Information Any past or current medical problems (including surgeries, accidents, birth defects, depression, etc.)? If yes, please list: Yes No Do you have any known genetic disorders? If yes, please list: Yes No Have you ever been pregnant? If yes, how many times and what was the outcome? Yes No Have you ever been a donor before? If yes, did a pregnancy occur? Yes No Are you currently taking any medication (for physical or mental health)? If yes, what medications are you on and why? Yes No Are you taking any recreational drugs? If yes, what are you taking? Yes No How often do you exercise? Family Member Information Father Age Height Occupation Motherr Age Height Occupation Paternal grandfather Age Height Occupation Maternal grandfather Age Height Occupation Maternal grandmother Age Height Occupation Sibling #1 Age Height Occupation Sibling #2 Age Height Occupation Sibling #3 Age Height Occupation If you have more than 3 siblings, please give their age, height and occupation below. Family Member Information - disorders Family Member Father Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Sibling #1 Sibling #2 Sibling #3 Age Mental Retardation Cancer Intellectual Disability Autism Spectrum Disorder Congenital Physical Malformation Cystic Fibrosis Lupus Hypertension (High Blood Pressure) Memory Loss / Dementia Depression Kidney Disease Bipolar Disorder Cardiomyopathy Allergies / Hay Fever ADHD (ADD/ADHD) Anemia Birth Defects Blindness History of Blood Transfusion Canavan Disease Additional information Family Member Father Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Sibling #1 Sibling #2 Sibling #3 Age Mental Retardation Cancer Intellectual Disability Autism Spectrum Disorder Congenital Physical Malformation Cystic Fibrosis Lupus Hypertension (High Blood Pressure) Memory Loss / Dementia Depression Kidney Disease Bipolar Disorder Cardiomyopathy Allergies / Hay Fever ADHD (ADD/ADHD) Anemia Birth Defects Blindness History of Blood Transfusion Canavan Disease Additional information Family Member Father Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Sibling #1 Sibling #2 Sibling #3 Age Mental Retardation Cancer Intellectual Disability Autism Spectrum Disorder Congenital Physical Malformation Cystic Fibrosis Lupus Hypertension (High Blood Pressure) Memory Loss / Dementia Depression Kidney Disease Bipolar Disorder Cardiomyopathy Allergies / Hay Fever ADHD (ADD/ADHD) Anemia Birth Defects Blindness History of Blood Transfusion Canavan Disease Additional information If you have more than 3 familiy members with medical disorders, please specify with details below. Can you send us a few pictures of you? I swear or affirm that the above and foregoing representations are true and correct to the best of my information, knowledge, and belief. Sign date 寄送
