Intended Parent Application CONFIDENTIAL Instructions: Within this online form you will be required to provide the following accompanying documents : - Pictures of yourself/partner/family. (additional pictures can be sent to email@example.com) - Picture of government issued identification (such as a driver's licence/passport/health card). Once we receive your application we will contact you by email regarding your payment of the Surrogacy in Canada Online fee (We accept PayPal, Interac email transfer, certified cheques/money orders and personal cheques. Please make cheques and money orders payable to "Surrogacy in Canada Online".) You will not be asked to make an online payment at the end of this form. Surrogacy in Canada Online will keep all of the information on your application confidential. Your information will only be shared with your potential surrogate mother, IVF clinic/physician, legal parties, and mental health providers after we have received your expressed permission to do so.Intended Parent's (1) Full Name:(Required) First Last Intended Parent's (2) Spouse/Partner’s Full Name (if applicable): First Last Intended Parent's (1) Date of Birth:(Required) MM slash DD slash YYYY Intended Parent's (1) Age:(Required) Intended Parent's (2) Spouse/Partner’s Date of Birth: MM slash DD slash YYYY Intended Parent's (2) Spouse/Partner’s Age: Mailing Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number:(Required)(No dashes, spaces or special characters +,?, etc)Cell/Mobile Phone Number :(No dashes, spaces or special characters +,?, etc)Is it okay to leave messages related to surrogacy on your answering machine/voicemail?(Required) Yes No Is it okay to receive mail labelled with surrogacy related return addresses?(Required) Yes No Email Address:(Required) Citizenship:(Required) What is your marital status?(Required) Single Single and Dating In a Relationship Engaged Married Separated Divorced Widowed Common Law/Cohabiting Are you religious?(Required) Yes No What is your religion?(Required) Intended Parent (1) What is your ethnic background?(Required) Intended Parent (2) Spouse/Partner's ethnic background: Intended Parent (1) What is your occupation?(Required) Intended Parent (2) Spouse/Partner's occupation: If requested, are you willing to submit to a criminal background check to your surrogate mother?(Required) Yes No Intended Parent (1) Have you ever (please check all that apply and provide dates): been charged with child neglect or abuse been in a substance abuse program been arrested filed for bankruptcy been evicted been foreclosed upon Please provide dates for any items selected above:Intended Parent (2) 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 filed for bankruptcy been evicted been foreclosed upon Please provide dates for any items selected above:Do you have any children?(Required) Yes No Please include name, age, gender of your children:Reason for pursuing surrogacy and/or egg donation...(Required) Infertility Secondary Infertility Medical Condition Age Sexual Orientation Other For how long have you been trying to become a parent?(Required) What procedures have you tried so far (if any)?(Required) Are you a patient of an IVF clinic (if so which one)?(Required) Do you have frozen embryos?(Required) Yes No Have your frozen embryos been genetically screened? Yes No Unsure Do you have a fertility lawyer (or have consulted with one yet)?(Required) Yes No Which lawyer(s)? Have you applied with any other surrogacy consultants/programs?(Required) Yes No Which surrogacy consultants/program(s)? How many children would you like to parent as a result of surrogacy?(Required) If your surrogate mother becomes pregnant with twins, would you want her to undergo selective reduction to reduce the number?(Required) Yes No Unsure If your surrogate mother becomes pregnant with triplets or higher, would you want her to undergo selective reduction to reduce the number?(Required) Yes No Unsure If your surrogate mother becomes pregnant with a fetus (or fetuses) that has serious physical or mental disabilities/abnormalities, would you ask her to abort?(Required) Yes No Unsure Depends on the abnormality When would you like to enter into a surrogacy arrangement?(Required) Are you financially prepared for the surrogacy process and have reviewed the costs involved on our Cost of Surrogacy page? Yes No What qualities would you like your surrogate mother to have?(Required)Many surrogate mothers like to share about their surrogacy experience with an online blog/Facebook/Instagram page/groups etc. Are you supportive of your surrogate mother sharing about her experience (while respecting your privacy with identity/photos?)(Required) Yes No Unsure Please describe the level of involvement you would like with your surrogate mother before, during and after the pregnancy (such as attending doctor's visits, being present at the delivery, telephone calls, etc):(Required)Would you request that your surrogate mother provide breastmilk for your baby?(Required) Yes No Unsure For how long?(Required) If your child asks to meet your surrogate mother, how will you feel?(Required)Do you plan to be open and honest with your child/children regarding the circumstances of their conception/birth via surrogacy?(Required)Do you fully understand that Surrogacy in Canada Online cannot guarantee you will match with a surrogate mother and will be assisting you with introductions, support and referral?(Required) Yes No Supporting DocumentsPlease provide Surrogacy in Canada Online with the following documents. (If having trouble uploading, you can email pictures directly to firstname.lastname@example.org)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. Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 15 MB.Images of yourself/partner/family. Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 15 MB, Max. files: 5. Please upload up to 5 images.RELEASE AND INDEMNIFICATIONI/We, (Intended Parent(s)) (referred to jointly as "Intended Parent[s]") ACKNOWLEDGE, AGREE AND SWEAR TO THE FOLLOWING TERMS: 1. It is my/our desire to enter into a surrogacy arrangement with a surrogate mother and her spouse/partner in an attempt to become parents (or parent). 2. Surrogacy in Canada Online did not coerce, induce or unduly influence my/our decision to apply to be an intended parent. 3. Surrogacy in Canada Online is not party to any agreement that I/we may enter into with a surrogate mother. 4. Surrogacy in Canada Online makes no representations, warranties or guarantees regarding the potential surrogate mother and the surrogacy process and I/we understand and agree that they cannot predict or control the surrogate mother and her spouse/partner or how a court may interpret or enforce any surrogacy agreement I/we may enter into with a surrogate mother and her spouse/partner. 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 surrogate mother and/or her spouse/partner. 5. Surrogacy in Canada Online will ensure my/our application and the information I/we provided with it to be kept strictly confidential unless I/we have given expressed permission for it to be shared with a potential surrogate mother or surrogacy professional (IVF clinic/doctor/lawyer/psychologist/social worker). 6. 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 engage in surrogacy and any adverse consequences or damages that may result from my/our involvement with the surrogacy process. 7. I/We hereby agree to indemnify, and hold harmless Surrogacy in Canada Online, their employees and representatives against liability as well as against loss, and for any and all costs incurred defending any complaints, actions or claims as directly related to the services I/we received. 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 our own accord not to consult with legal counsel. 9. I/We understand that Surrogacy in Canada Online services do not guarantee a match with a potential surrogate mother and/or the live birth of a child. 10. I/We agree to inform Surrogacy in Canada Online if, at any time during my/our membership, I/we no longer wish to (or unable to) proceed with a surrogacy arrangement. As well I/we agree to inform Surrogacy in Canada Online if I/we during my/our membership have found an independent match or match through another surrogacy consultant/organization. 11. 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. 12. I/We hereby certify that I am requesting access to the members section solely for the purpose of looking at prospective surrogate mothers. 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 IP address will be used to pursue legal action against me/us for attempting to gain access to this program for any other purposes. 13. 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. 14. I/We understand THERE ARE NO REFUNDS FOR THESE SERVICES. I/WE, THE UNDERSIGNED, HAVE READ THE ABOVE RELEASE AND INDEMNIFICATION. WE UNDERSTAND ITS TERMS AND AGREE TO BE BOUND BY ITS TERMS. The following box must be selected in order to submit your application.(Required) I/We agree to the terms listed above and all of the information I/we have provided to Surrogacy in Canada Online in this application is complete, true and accurate to the best of my/our knowledge.Intended Parent 1 Applicant Signature:(Required) Reset signature Signature locked. Reset to sign again I understand this is a legal representation of my signature.Date(Required) MM slash DD slash YYYY Intended Parent 2 Applicant Signature: Reset signature Signature locked. Reset to sign again I understand this is a legal representation of my signature.Date MM slash DD slash YYYY CAPTCHAPlease wait until you see the thank you page before closing this page as images may cause this form to take time to process.