Surrogate Application

Welcome to Surrogate Steps where we will guide you through each step of the process. Thank you for taking the first step in making a family’s dream come true.

Please fill out the information below to begin your journey.

"*" indicates required fields

Step 1 of 5

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Name*

First Last

Email*

Phone Number*

Location*

City State

Age*

How many children have you had?*

Height (Feet)*

Enter Height Above in Feet

Height (Inches)*

Enter Height Above in Inches

Weight*

(Enter pounds)

BMI

Is it okay to leave a message?*

Yes

Thank you for your interest in Surrogate Steps! We appreciate your support, but unfortunately due to state laws and regulations, we cannot accept applicants from your state at this time.

Thank you for your interest in Surrogate Steps! We appreciate your support, but unfortunately, one of the prerequisites clinics have set for becoming a surrogate is that the applicant must be between the ages of 23 and 43, must have a BMI under 34, and must have given birth to a healthy baby with no complications. Therefore, considering your answers to this application, we will not be following up with you at this time.

Disclaimer

Does anyone in your home, including yourself, smoke or take drugs?*

Yes

Would you be willing to quit and be smoke free for 6 months prior to and for the duration of the entire surrogacy process?*

Yes

Does anyone in your home, including yourself, smoke or have medical marijuana?*

Yes

Would you be willing to quit and be Marijuana free for 3 months prior to and for the duration of the entire surrogacy process?*

Yes

Are you exposed to any chemicals on a regular basis that might be harmful to a fetus?*

Yes

Would you be willing to make the necessary lifestyle changes to avoid all such harmful chemicals for the duration of the surrogacy process?*

Yes

Disclaimer: Please note that if you have ever been medically diagnosed with endometriosis, pre-eclampsia, post-partum depression or an eating disorder, or if you are currently on any medication for depression/anxiety, you are unable to become a surrogate.

Do any of these conditions apply to you?*

Yes

Thank you for your interest in Surrogate Steps! We appreciate your support, but unfortunately, your responses do not match with our basic health criteria and we will not be following up with you at this time.

Tell Us More About Yourself

Are you generally healthy?*

Yes

Have you been vaccinated against COVID-19?*

Yes

Did you have any complications with your prior pregnancies or deliveries?*

Yes

Have you ever smoked?*

Yes

If yes, how long ago and for how long?

Do you drink alcohol?*

Yes

Have you received any tattoos or body piercings in the last 6 months?*

Yes

Are you currently breastfeeding?*

Yes

Are you a US Citizen?*

Yes

Do you have a valid driver’s license?*

Yes

Do you have pets?*

Yes

If yes, please list all types

What is your ethnic background?*

Caucasian

African American

Asian

Latin American

Other

Rather not say

What is your religious background?*

Christian

Jewish

Muslim

Aetheist

Other

Rather not say

What is your level of education?*

Partial High School

High School or GED

Partial College

Bachelors Degree

Masters Degree

PhD or Doctorate

Are you currently employed?*

Yes

What is your annual household income?

Are you currently on public assistance?*

Yes

Are you on food stamps?*

Yes

Have you filed for bankruptcy in the last 7 years?*

Yes

Have you ever been convicted of a crime?*

Yes

If yes, please explain

Thank you for your interest in Surrogate Steps! We appreciate your support, but unfortunately, we are unable to work with women who receive some forms of public assistance. This is a requirement of the IVF clinics that we work with, and therefore we will not be following up with you at this time.

Tell Us More About Your Support System

What is your marital status*

Do other adults (besides a partner) live in your home*

Yes

If yes, what is their relationship to you?

Is your family supportive of your decision to be a surrogate?*

Yes

Is your partner supportive of your decision to become a surrogate*

Yes

N/A

How long have you been together?

Do you live together?*

Yes

Have you ever experienced serious relationship problems or domestic violence in your relationship?*

Yes

Are the children that you have related to your partner or spouse?*

Yes

What is your partner's level of education:*

Partial High School

High School or GED

Partial College

Bachelors Degree

Masters Degree

PhD or Doctorate

Is your Partner employed?*

Yes

If yes, do they work from home?*

Yes

Has your Partner filed for bankruptcy in the last 7 years?*

Yes

Tell Us What You're Comfortable With

During the surrogacy pregnancy, are you comfortable having contact with the intended parents to give them updates regarding the pregnancy?*

Yes

Are you comfortable leaving post birth contact decisions up to the intended parents, with an understanding that it will depend on the relationship you all develop during the pregnancy?*

Yes

Are you comfortable leaving all future contact with the child that will be born up to the intended parents, with an understanding that it will depend on the relationship you all develop during the pregnancy?*

Yes

Do you feel comfortable having intended mother in the delivery room while you give birth?*

Yes

Do you feel comfortable having intended father in the delivery room while you give birth?*

Yes

If the parents ask, would you be willing to pump, freeze and ship your breast milk for the child?*

Yes

Do you feel confident that you will give the intended parents their child when it is born?*

Yes

Name

This field is for validation purposes and should be left unchanged.