Start your journey to parenthood We’ll use this form to get some quick information about you and get started with the parent process! Once you submit your application, Stronger Together Surrogacy will contact you via E-Mail and Text within 24-48 hours (if not sooner!)Fields marked with an * are required. IP - unique IDSUR - unique IDI am interested in?(Required) Becoming a Parent Becoming a Surrogate I/We are a (select one) looking for a surrogate(Required)(please select one)Hetero Couple/SingleSame sex Couple/SingleOtherIf Other, please describe(Required) Name(Required) First Last Email(Required) Cell Phone(Required)Date of Birth(Required) Month Day Year Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican 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 Relationship status (select one)(Required)(please select one)CommittedEngagedMarriedSingleOtherPartner's Name (if applicable) First Last Partners Date of Birth (if applicable) Month Day Year Partners Email (if applicable) Partners Cell Phone (if applicable)When are you looking to begin?(Required) As soon as possible Within the next 6 months Within the next year Are you already using a fertility clinic?(Required)(please select one)YesNoPlease provide their name and contact information of clinic Do you already have two or more embryos?(Required)(A detailed embryo report will be requested)(please select one)YesNoDo you already have a family formation attorney?(Required)(please select one)YesNoIf yes, please provide their name and contact information Please tell us a bit about yourself(s) (Professions, lifestyle, hobbies, interests, etc)(Required)Comments or questions:Are you a U.S. Citizen or Legal Resident?(Required)(please select one)YesNoAre you a member of a Native American tribe?(Required)(please select one)YesNoRelationship status (select one)(Required)(please select one)Legally MarriedEngagedIn a Relationship (Cohabitating)In a Relationship (Living Separately)SingleDivorced (Finalized)Divorced (In Process)Legally SeparatedSeparated (Non-Legal)OtherAre you currently employed?(Required)(please select one)YesNoPlease describe your employment and what your hourly pay or weekly salary is?(Required) If not, is your partner currently employed?(Required)(please select one)YesNoPlease describe your partners employment and what their weekly pay is?(Required) Height:(Required) Weight:(Required) Do you smoke or vape of any kind?(Required)(please select one)YesNoDo you have any known allergies?(Required)(please select one)YesNoIf yes, please describe(Required) Are you using birth control?(Required)(please select one)YesNoIf yes, what kind?(Required) Do you currently take any medication(s)?(Required)(please select one)YesNoIf yes, what kind, and what is it for?(Required) Have you had any surgeries or medical procedures?(Required)(please select one)YesNoIf yes, what type, and what is it for? Please include the year the procedure was done.(Required) Do you currently, or have a history of depression or anxiety?(Required)(please select one)YesNoHave you ever attempted suicide?(Required)(please select one)YesNoPlease describe the situation?(Required) Do you currently, or have a history of seizures or heart condition?(Required)(please select one)YesNoDo you have a history of miscarriage(s)?(Required)(please select one)YesNoHow many? What Years?(Required) Have you had an elective termination?(Required)(please select one)YesNoHow many? What Years?(Required) Have you ever had any fertility treatment?(Required)(please select one)YesNoPlease explain the situation.(Required) Have you been a surrogate before?(Required)(please select one)YesNoHow many children have you delivered? (In order to be a surrogate you have to have delivered at least one child prior)(Required)(please select one)012345678910PLEASE LIST (ALL) THEIR DETAILS BELOW (Month & Year Born, Weeks at birth, Weight, Vaginal/C-section, Biological/Surrogacy):(Required)Did you have any complication during any of these pregnancies?(Required)(please select one)YesNoPlease describe what pregnancy this was and what the complications were.(Required) Are you currently nursing or pumping?(Required)(please select one)YesNoWhen do you anticipate stopping?(Required) Do you have or have you ever had any of the following medical conditions?(Required)(Check all that apply or None of the above) Herpes Gestational Diabetes Per-Term Labor Pre-Term Delivery Placenta Previa Placenta Abruption High Blood Pressure Pre-Eclampsia Bed Rest (During Pregnancy) Shortening of Cervix Cervical Cerclage Post-Partum Depression Uterine/Ovarian Cysts Uterine/Ovarian Fibroids Cesarean Section Other None of the above Please describe the medical condition. Please upload a photo for your profile. (Additional photos will be requested when your profile is created)(Required)Accepted file types: jpg, jpeg, png, gif, Max. file size: 1,000 MB.OLD - Please upload a photo for your profile. (Additional photos will be requested when your profile is created)Accepted file types: jpg, jpeg, png, gif.Comments or Questions?How did you hear about us?(Required)(Please Select One)Google/Other web searchFacebook/InstagramFriend/Family: Tell us who to thankFertility Clinic: Tell us who to thankProfessional: Tell us who to thankWho should we thank?(Required)