Apply to be a Surrogate

What is your Date of Birth?

Thank you for your interest. However, at this time American Surrogacy is not accepting surrogates who are younger than 21 or older than 38 years of age.

Are you receiving any assistance from the State? (check all applicable)

Income Assistance/SSI

Housing Assistance HUD

Food Assistance (Stamps)

Food Assistance (WIC)

Healthcare Assistance - Medicaid

Thank you for your interest. However, based on American Society for Reproductive Medicine (ASRM) guidelines, at this time American Surrogacy is not accepting surrogates who are on Medicaid or Food Stamps. ASRM is dedicated to the advancement of the science and practice of reproductive medicine and sets forth these recommendations for all surrogacy professionals. If your circumstances change and you no longer receive Medicaid benefits, please re-submit your application.

If you have had a tattoo/piercings done in the last 12 months, please tell us the approximate date it was done.

Thank you for your interest. However, based on American Society for Reproductive Medicine (ASRM) guidelines, at this time American Surrogacy is not accepting surrogates who have had tattoo done in the last 6 months. If your circumstances change, please re-submit your application.

If you have had anti-depressant/anxiety medications in the last 12 months, please tell us the approximate last date you had it.

Thank you for your interest. However, based on American Society for Reproductive Medicine (ASRM) guidelines, at this time American Surrogacy is not accepting surrogates who have had anti-depressants/anxiety medications in the last 6 months. If your circumstances change, please re-submit your application.

What kind of Medical Coverage do you have?

Have Medicaid. Need help with medical expenses. Have Private Insurance. Have Tricare.

Thank you for your interest. However, based on American Society for Reproductive Medicine (ASRM) guidelines, at this time American Surrogacy is not accepting surrogates who are on Medicaid. ASRM is dedicated to the advancement of the science and practice of reproductive medicine and sets forth these recommendations for all surrogacy professionals. If your circumstances change and you no longer receive Medicaid benefits, please re-submit your application.

Have you ever given birth?

Yes No

Based on American Society for Reproductive Medicine (ASRM) it is required that all potential surrogates have given birth to at least one child. If your circumstances change please feel free to submit an application again. Thank you for your interest in American Surrogacy!

What is the date of birth for the last child you delivered?

Based on American Society for Reproductive Medicine (ASRM) it is required that you must wait at least 4 months after a child birth. If your circumstances change please feel free to submit an application again. Thank you for your interest in American Surrogacy!

Was the last child delivered via C-Section?

Yes No

Based on American Society for Reproductive Medicine (ASRM) it is required that you must wait at least 10 months after a C-Section delivery. If your circumstances change please feel free to submit an application again. Thank you for your interest in American Surrogacy!

Are you parenting at least one child in the home (the child must live with you)?

Yes No

Thank you for your interest in American Surrogacy but at this time American Surrogacy is only accepting applicants who are parenting at least one child in the home based on American Society for Reproductive Medicine (ASRM) guidelines. If your circumstances change please feel free to submit an application again.

Do you smoke?

Yes No

Are you exposed to second hand smoke?

Yes No

Based on American Society for Reproductive Medicine (ASRM) it is required that all potential surrogates be smoke free and free from second hand smoke for at least 6 months. If your circumstances change please feel free to submit an application again. Thank you for your interest in American Surrogacy!

Height ft in Weight lb

American Surrogacy is not able to work with any surrogates who have a BMI over 35 at this time. We follow American Society for Reproductive Medicine (ASRM) guidelines which have been established to protect the health of surrogates and newborns. To learn more about calculating your BMI please visit:http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm If your circumstances change please feel free to submit an application again. Thank you for your interest in American Surrogacy!

How ready are you to begin the surrogacy process?

Still researching, but would like more information.

Have researched surrogacy and would like to speak to a surrogacy specialist to find the best fit.

Ready to begin the process and set up a consult.

Contact Info

I would like to receive info / be contacted by (check at least one)

Phone

Mail

First Name: Last Name: Email Address: Phone

area code

phone number

Best Day/Time to Call: OK to Text (SMS)?

Yes No

Can we leave identifying message in the voice mail?

Yes No

Skype Account Name: OK to Video Chat?

Yes No

Address:

: City:

: State:

Zip:

Tell us a little about yourself

Citizenship: Your Race:

African American

Asian

Caucasian

Hispanic

Native American

Other

Marital Status Have you ever been convicted of a felony? (Please note that we will complete a criminal background check)

Yes No

Do you have reliable transportation?

Yes No

Are you able to travel for surrogacy related trips?

Yes No

Have you experienced any complications during the pregnancy?

Yes No

How many miscarriages or stillbirths have you had? How many children are living with you? How many cesarean births have you had? Are you currently breastfeeding?

Yes No

What is the approximate date of your last papsmear? Have you completed your family?

Yes No

Have you ever been a surrogate before?

Yes No

Why are you interested in becoming a surrogate? Type of intended parent(s) you are comfortable working with? (check all applicable)

Male/Female Single Male Single Female Same Sex Male Same Sex Female

Are you comfortable working with international parents?

Yes No

Are you comfortable work with Non-English speaking parents?

Yes No

How did you hear about us? Additonal Comments:

or contact us at 1-800-875-BABY (875-2229) now

Surrogate Contact

Contact Info

Tell us a little about yourself