Surrogate Application Form

Apply today to become a surrogate!

Give one of the greatest gifts anyone can ever give… the gift of life.

Please use the following form to apply to be a surrogate.

Confidential

Please note that your information is saved on our server as you enter it.

Instructions:

Within this online form you will be required to provide the following accompanying documents :

- Pictures of yourself/partner/family.
- Picture of government issued identification (such as a driver's licence/passport/health card).
- Please send additional pictures (preferably 5-10) to sally@surrogacy.ca

Surrogacy in Canada Online will keep all of the information on your application confidential except for purposes related to surrogacy services. Therefore, this information will be shared with prospective parents, physicians, lawyers, and mental health providers as needed.

***This application may take about 10 minutes to complete.***
Surrogate's Full Name:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Age:*
Citizenship: (You must be a Canadian Citizen or permanent resident of Canada to be considered).*
Height:*
Weight:*
Mailing Address: Please enter FULL address correctly otherwise you may miss out on packages/deliveries!*
Street Address Address Line 2 City Province Postal Code
Phone Number: (No dashes, spaces or special characters +,?, etc)*
If this is a cell phone, is it okay for SCO to send you a text message?*
- Yes
- No
Alternate Phone Number: (No dashes, spaces or special characters +,?, etc)
If this is a cell phone, is it okay for SCO to send you a text message?
- Yes
- No
Are you comfortable with receiving text messages from potential intended parents?*
- Yes
- No
Are you comfortable with your phone number and address showing on your profile to intended parents or prefer it's kept hidden?*
- Okay to show
- Prefer it's hidden
Can we call you directly when we receive your application or would you prefer an appointment?
- Open to Call!
- Prefer Appointment
Email Address (Please double check you have entered the correct email otherwise we will be unable to contact you):*
Please include your name on Facebook if it is okay for us to message you and add you to our private surrogate support group.
What is your marital status?*
- Single
- Single and Dating
- In a Relationship
- Engaged
- Married
- Separated
- Divorced
- Widowed
- Common Law/Cohabiting
Spouse/Partner's Full Name (if applicable):
First Last
How many children have you given birth to?*
Have you ever lost custody of your child(ren)?*
- Yes
- No
Do you have any step/foster/adopted children?*
- Yes
- No
Please list first name(s), sex and age(s) of your child(ren).*
Are you pregnant?*
- Yes
- No
Are you adopted?*
- Yes
- No
Do you speak French? (Please only check yes if you are fluent in French).*
- Yes
- No
How would you describe your place of residence?*
- Home Ownership
- Home Rental
- Apartment/Condo Ownership
- Apartment/Condo Rental
- Living with Family Member(s)
- Dormitory/School
- Boarding House
- Co-Operative Housing
- Low/Geared to Income Housing
- Other
What is your ethnic background (such as Irish/Scottish/French etc.)?*
What is your occupation?*
What is your spouse's/partner's occupation?
If you are receiving financial/government assistance please indicate which one(s):
- Social Assistance/Welfare
- Disability
- Child Support
- Spousal Support
- Child Tax/Benefit
- Employment Insurance
- Student Financial Aid
- Other
Have you ever placed a child for adoption?*
- Yes
- No
Are you willing to provide a criminal background check to the intended parents if requested?*
- Yes
- No
Have you ever (please check all that apply):
- been charged with child neglect or abuse
- been in a substance abuse program
- been arrested and charged
- filed for bankruptcy
- been evicted
- been foreclosed upon
Has your spouse/partner ever (please check all that apply and provide dates):
- been charged with child neglect or abuse
- been in a substance abuse program
- been arrested and charged
- filed for bankruptcy
- been evicted
- been foreclosed upon
Please select the highest education level attained:*
- High School Graduate
- Trade school
- College Graduate
- University Graduate
Have you ever been a surrogate before?*
- Yes
- No
If you answered yes to the above question please provide more details.
Have you ever donated eggs before?*
- Yes
- No
If you answered yes to the above question please provide more details.
Which type of intended parents are you interested in helping? (Please select all that you are willing to help).*
- Select All
- I am open to ALL intended parents
- heterosexual intended parent(s)
- same-sex intended parent(s)
- a single man
- a single woman
- intended parent(s) using an egg donor
- intended parent(s) using a sperm donor
- intended parent(s) using donated embryos
- international intended parent(s) (You are not required to leave the country during the pregnancy, the intended parents will travel to Canada to visit you).
- intended parents that already have a child
- intended parent(s) using an egg/sperm or embryo from a deceased individual
Have you ever had an endometrial ablation procedure? (Burning of the uterine lining).*
- Yes
- No
Have you ever had weight loss surgery (such as gastric sleeve or bypass)?*
- Yes
- No
Do you have any medical problems?*
- Yes
- No
If you answered yes to the above question please provide more details.
Are you currently taking any medications?*
- Yes
- No
If you answered yes to the above question please provide more details.
Are you currently breastfeeding?*
- Yes
- No
Do you have menstrual periods every month?*
- Yes
- No
Number of pregnancies:*
Number of stillbirths:
Number of miscarriages:
Number of live births:*
Number of terminations:
List each of your delivery dates, whether they were vaginal or caesarean, how many weeks you delivered at, and the weight of each baby.*
Have you ever received fertility treatment in an effort to become pregnant?*
- Yes
- No
Did you have any severe complications with any of your pregnancies or births?*
- Yes
- No
If you answered yes to the above question please provide more details.
If any of your children are deceased, please state cause of death and the age of child at death:
Please list any and all emotional and/or physical problems you had with each pregnancy, delivery or after delivery:
Have you ever experienced post partum depression? (PPD is different from baby blues after birth. PPD is more powerful and lasts longer with severe mood swings, exhaustion, sense of hopelessness and thoughts of harming yourself and/your baby).*
- Yes
- No
Have you ever been diagnosed with an emotional condition or illness?*
- Yes
- No
Have you ever attempted suicide?*
- Yes
- No
Have you ever been treated by a mental health professional?*
- Yes
- No
If you answered yes to the above question please provide more details.
Do you smoke, vape, or are exposed to second hand smoke?*
- Yes
- No
Do you use any illegal/recreational drugs or drink more than 3 glasses of alcohol per week?*
- Yes
- No
Please describe your interests and/or hobbies…*
Please select with type of birth control you are currently using:*
- IUD
- Birth Control Pills
- Hormonal Injection, Patch, Implant or Ring
- Condoms
- Vasectomy/Tubal Ligation
- Diaphragm
- Natural/Calendar
- Not using any birth control methods.
Have you ever had (or been treated for) a sexually transmitted disease?*
- Yes
- No
If you answered yes to the above question please provide more details.
Please check all that apply...*
- I am interested in being a gestational surrogate only (no genetic relation to the child - not your eggs).
- I am interested in being a traditional surrogate only (genetic relation to the child - also donating your eggs).
- I am interested in being either a gestational surrogate or traditional surrogate.
What attracted you to surrogacy?*
What would you like to say to prospective intended parents?*
What reassurance can you give intended parent(s) that you will not change your mind about relinquishing the child(ren) you carry?*
What type of contact would you like from your intended parent(s) before, during, and after the pregnancy?*
Please include a 1-3 sentence blurb for under your profile photo such as "I have always wanted to be a surrogate", "I love to help others and babies are a wonderful gift. I'm hoping to make your dream come true!" or "I love being pregnant!"*
Would you be willing to carry twins?*
- Yes
- No
- Undecided
Would you be willing to selectively reduce in the event of high order multiples (twins, triplets, quads)?*
- I will not selectively reduce under any circumstance
- I will only selectively reduce if my health and/or the health of the pregnancy is at risk.
- I will leave the decision to selectively reduce up to the intended parents.
- I'm not sure...
Selective reduction is the practice of reducing the number of fetuses in a multiple pregnancy. This procedure is usually performed in the first trimester of a high risk pregnancy (and rare in surrogacy).
Would you be willing to have an amniocentesis and other diagnostic testing to check for birth defects or other problems with the fetus?*
- Yes
- No
- I will leave the decision for an amniocentesis up to the intended parents.
- I'm not sure...
If there was a severe medical problem with the fetus and the intended parents wanted you to terminate the pregnancy, would you be willing to honour their wishes?*
- Yes, the decision is up to the intended parents.
- No, I will not terminate a pregnancy for any reason.
- Only if the child will not survive after birth and/or the condition cannot be corrected.
- I'm not sure...
Would you allow the intended parents to attend doctor's appointments and be present during the birth?*
- Yes
- No
If the parents requested, would you be willing to pump, freeze and ship your breast milk for the baby?*
- Yes
- No
Are you open to meeting any children you give birth to as a surrogate when they become an adult?*
- Yes
- No
Supporting Documents
Please provide Surrogacy in Canada Online with the following documents. (If having trouble uploading, you can email pictures directly to sally@surrogacy.ca)
Picture of government issued identification (such as a driver's license/passport/health card). We require government issued identification for our program. If you are having issues sending the photo via this form we will follow up by email to receive a copy.
Max. file size: 40 MB.
Image of yourself for your profile photo (clear headshot if possible).
Max. file size: 40 MB.
Image of yourself/partner/family.
Max. file size: 40 MB.
Image of yourself/partner/family.
Max. file size: 40 MB.
Image of yourself/partner/family.
Max. file size: 40 MB.
Image of yourself/partner/family.
Max. file size: 40 MB.
RELEASE AND INDEMNIFICATION
I/We, (referred to as "Surrogate Mother Applicant") AND (referred to as "Spouse/Partner of Surrogate Mother applicant")

ACKNOWLEDGE, AGREE AND SWEAR TO THE FOLLOWING TERMS:

1. It is my/our desire to enter into a surrogacy arrangement with individuals who desire to become parents. All of the information I have provided to Surrogacy in Canada Online in this application is complete, true and accurate to the best of my knowledge.

2. Surrogacy in Canada Online did not coerce, induce or unduly influence my/our decision to apply to be a surrogate mother.

3. Surrogacy in Canada Online does not represent me/us or will be providing us with legal or medical counsel.

4. Surrogacy in Canada Online is not party to any agreement that I/we may enter into with intended parents.

5. Surrogacy in Canada Online makes no representations, warranties or guarantees regarding the intended parents and the surrogacy process and I/we understand and agree that they cannot predict or control the intended parents or how a court may interpret or enforce any surrogacy agreement I/we may enter into with intended parents. Furthermore, I/we acknowledge that Surrogacy in Canada Online, their employees and representatives do not have the authority or ability to predict or control my/our actions, conduct, negligence, or my/our failures to act nor the authority or ability to predict or control the actions, conduct, negligence, or failure to act of the intended parents.

6. Surrogacy in Canada Online will be providing my/our application/photos and the information I/we provided to prospective intended parents electronically and/or in print. This information will also be provided to the IVF clinic, lawyers and social worker/psychologist involved with any resulting match. I/We acknowledge that Surrogacy in Canada Online provides my/our information to prospective intended parents, IVF clinic, lawyers and social worker/psychologist and hereby consent to my/our application and related information being provided electronically and/or in print. I/We acknowledge that Surrogacy in Canada Online can remove/delete all my/our information upon request.

7. I/We hereby release and discharge Surrogacy in Canada Online, their employees and representatives from all liability and all manners of action, suits, causes of actions, proceedings, debts, claims, an demands whatsoever in law or equity resulting from my/our decision to be a surrogate mother and any adverse consequences or damages that may result from my/our involvement with the surrogacy process.

8. I/We have had the opportunity to consult with legal counsel regarding this Release and Indemnification and have done so or have decided on my/our own accord not to consult with legal counsel.

9. I/We agree to inform Surrogacy in Canada Online if, at any time, I/we no longer wish to and/or am unable to participate, as well as if I become involved with intended parents for surrogacy through any other means and/or organization.

10. I/We understand that in order to gain access to the members section of Surrogacy in Canada Online, my/our contact information is required and that both my email and the IP address will be recorded by Surrogacy in Canada Online.

11. I/We hereby certify that I am requesting access to the members section solely for the purpose of looking at prospective intended parents. All other purposes are unauthorized. I further acknowledge that to protect the privacy of all participants in Surrogacy in Canada Online program, both my email and the IP address will be used to pursue legal action against me/us for attempting to gain access to this program for any other purposes.

12. I/We agree to maintain a level of respect and courtesy to all Surrogacy in Canada Online staff and members. Failure to do so will result in my/our immediate removal as members of Surrogacy in Canada Online.
The following box must be selected in order to submit your application.*
I/We agree to the terms listed above.
Surrogate Mother Applicant Signature. Type your name into the box below.*
Date*
MM slash DD slash YYYY
Husband/Partner of Surrogate Mother Applicant Signature. Type your name into the box below.
Date
MM slash DD slash YYYY

Surrogate Application Form

Apply today to become a surrogate!

Please use the following form to apply to be a surrogate.

Supporting Documents

RELEASE AND INDEMNIFICATION