iparentapp

Name:
Reason For Contact:
Person you wish to contact (if known):
Phone:
Desire Call
Street Address
City
State
Zip Code
Phone
e-mail
May we leave messages on your home answering machine concerning egg donation - YES?
Date of Birth
Social Security Number
Drivers License Number
Your Occupation
Employer
Work Telephone
May we call you at your place of business (SPCT is always discreet when using your work number) ...YES?
How did you hear about Surrogate Parenting Center of Texas?
Physician? please specify:
Support Group? please specify:
Internet? please specify:
Friend or Acquaintance? please specify:
Other? please specify:
Would you like to view profiles of donors:
Only in your area?
All Available Profiles? Donors that are selected from outside of your area may require additional physician monitoring and travel expenses.
In the follwing choices please indicate your your level of flexibility for SPCT to use when selecting donor profiles. Type in: FIRM, FLEXIBLE, NOT SURE.
RACE:
Height Range:
Hair Color:
Eye Color:
Other? please specify:
In the box below, please provide a brief description of your family fertility history including doctors you have seen.

If you have a criminal record of any kind, please give a detailed record including offense,county, state and date in the box below:

If you have ever been denied acceptance to a surrogacy, egg donation, adoption or any child placing program, please provide a detailed acoount including agency, reason for rejection and date of rejection in the box below.

By checking the box at the right you are verifying that all the information you have submitted on this application is true, correct, and complete. This application is executed under penalty of perjury under the laws of the state of Texas.

Matching Factors
What level of contact are you expexting with your surrogate during the pregnancy?
Comments concerning contact with your surrogate during the pregnancy:
What level of contact are you expecting with your surrogate after delivery?
Comments concerning contact with your surrogate after the pregnancy.
If the fetus were determined to have a non-correctible handicap would you want your surrogate to abort the pregnancy?
If it were determined that your surrogate was carrying more than one fetus would you want the surrogate to undergo selective reduction? More than two?
What qualities are most important to you in choosing a surrogate?
Background Information
Do either of you have a criminal record? *If yes, provide a detailed account of record including offense, county, state, and date.
Have you ever been denied acceptance to a surrogacy, adoption or any other chiled placing program? *If yes, provide a detailed account including the agency, reason for rejection and date of rejection.
Have you ever been investigated by Child Protective Services or the like agency in any state or country? *If yes, provide a detailed account of the allegation including the country and the state of investigation.
I verify that the statemnets made and the information provided in this application are true, correct, and complete. This application is executed under the penalty of perjury under the laws of the state of Texas.
Husband	Wife
*Application Fee $85.00-Please submit to SPCT 7001 Preston Rd Ste. 215 Dallas TX 75205