Intended Parent Application Form

Thank you for completing our Intended Parent Application. We look forward to speaking with you about it soon.

This application contains multiple sections and completing the entire form takes approximately 20 minutes. Please note that the application must be completed all at once and cannot be saved to finish later.

Thanks again for your interest in our program.

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Citizenship Status *
Have you been fully vaccinated for COVID-19? *
Do you have any children? *
Marital Status *
Do you live together? *
Are you employed? *
Have you ever had your wages garnished? *
Have you ever been involved in a bankruptcy? *
Have you ever had a foreclosure filed against you? *
Have you ever had an eviction action of any kind filed against you? *
Have you ever had a collection action filed against you? *
Are you pursuing your surrogacy journey with a spouse or partner? *
Intended Parent 2: Citizenship Status *
Intended Parent 2: Have you been fully vaccinated for COVID-19? *
Intended Parent 2: Do you have any children? *
Intended Parent 2: Marital Status *
Intended Parent 2: Are you employed? *
Intended Parent 2: Have you ever had your wages garnished? *
Intended Parent 2: Have you ever been involved in a bankruptcy? *
Intended Parent 2: Have you ever had a foreclosure filed against you? *
Intended Parent 2: Have you ever had an eviction action of any kind filed against you? *
Intended Parent 2: Have you ever had a collection action filed against you? *

Please answer the following questions with respect to both Intended Parents jointly if there are 2 Intended Parents submitting this application.

Do you currently have medical insurance? *
Total savings *
How do you plan to fund your surrogacy journey? Check all that apply:

After clicking next step, please scroll up to continue with the form.

Have you ever worked with another surrogacy agency? *
Do you plan to work with more than one surrogacy agency simultaneously? *
Have you ever undergone a psychological screening before associated with assisted reproduction or surrogacy? *
Are you willing to undergo a psychological screening as part of your surrogacy journey with NYSC? *
Do you have an attorney selected to assist you with your surrogacy journey? *
Are you currently working with a fertility clinic? *
Do you plan to use this fertility clinic for your surrogacy journey? *
Do you know what fertility clinic you will use for your surrogacy journey? *
Do you currently have embryos available for surrogacy? *
What day were your embryos frozen? *
Have you genetically tested your embryos? *
What type of testing did you use? *
Are any of them mosaic? *
Do you plan to use your mosaic embryos for surrogacy? *
What is the source of the sperm used to create your embryos? *
Please check any of the following that Intended Parent 1 has been diagnosed with:
Please check any of the following that Intended Parent 2 has been diagnosed with:
Did the Known Embryos Donors use donor gametes to create the embryos? *
What is the source of the egg used to create your embryos? *
Please check any of the following that Intended Parent 1 has been diagnosed with:
Please check any of the following that Intended Parent 2 has been diagnosed with:
How many embryo transfer procedures will you be willing to undertake with your surrogate to achieve a pregnancy? *
Do you plan to select the sex of the embryos you transfer? *
Are you still attempting to achieve a pregnancy to be carried by Intended Parent 1 or 2? *

After clicking next step, please scroll up to continue with the form.

Have you ever used a surrogate before? *

For each of the following matching criteria, please indicate if you have a preference or do not have a preference. If you have a preference, please describe what your preference is. The more details you provide to us, the better.

Age *
Marital Status *
Number of Children *
Race *
Religion *
Sexual orientation *
Gender identity *
Employment/Type of Employment *
Location *
Surrogacy friendly insurance *
Experienced carrier (previously acted as surrogate) *
Recreational Use of Marijuana while NOT Pregnant *
Willing to do a Double Embryo Transfer due to low quality embryos *
Willing to do a double embryo transfer to try for twins *
Willing to pump breast milk *
Willing to act as your surrogate again in the future *
COVID-19 vaccination status *
Do you want to attend the surrogate’s medical appointments during the screening process and embryo transfer? *
Do you want to attend the surrogate’s medical appointments during the pregnancy? *
Do you want to be in the delivery room when your child is born? *
Do you want to visit your surrogate in her home? *
Do you want the surrogate to visit you in your home? *
Under which of the following circumstances would you want your surrogate to be willing to terminate the pregnancy (check all that apply):
Under which of the following circumstances would you want your surrogate to selectively reduce multiples even if all babies could be born healthy? (check all that apply):
Would you be willing to work with a surrogate who would want to selectively reduce multiples in the following circumstances even if all babies could be born healthy? (check all that apply):

After clicking next step, please scroll up to continue with the form.

Is all of the information contained in this application true and accurate to the best of your knowledge? *
Do you agree to notify NYSC immediately if any of the information contained in this application becomes incorrect or incomplete? *
Do you understand that the information contained in this application will be used by NYSC in determining whether you meet the eligibility requirements to act as an intended parent? *
Do you understand that the information contained in this application will be used by NYSC for purposes of screening potential surrogates and matching you with a Surrogate(s) that is a good fit for you? *
Do you authorize NYSC to provide this application, the information contained herein and the documents submitted in support of this application, to third parties as necessary to facilitate the surrogacy process including, but not limited to, the fertility clinic, any medical and/or psychological evaluators, insurance agents, escrow agents and/or attorneys for the parties? *
Do you authorize NYSC to share the information contained in this application (with the exception of financial information, social security numbers and contact information) with potential surrogates as part of the matching process? *