Elite Fertility Egg Donor Application Form

Thank you for considering becoming an egg donor with us! We can assure you that you will be well taken care of. We have created this convenient, online application, so that your application can be processed faster and you can start the screening process as soon as possible.

Please fill out this online application and submit when completed. When you submit the application, we will contact you via the email address you have provided to let you know if you have been approved to continue with the screening process. Be sure to fill out all of the fields and be as detailed as possible. If you have any questions about the application, please call our staff at 949-494-6511 or email at sherriparker@elitefertility.com.

Egg Donor Application Form

I certify that I have read all of the information provided and meet the initial requirements to become an egg donor. I am aware that, after receiving explicit instructions, I will be required to give myself daily injections of hormone medication for a period of time during the egg donation cycle.

Personal Information
 

Name:
Address:
City: State: 
Zip Code: Country: 
E-mail:
Home Phone:
Work Phone:
Cell Phone:
Date of Birth: Age:
Marital Status: Single Married Divorced
Pregnancies:
Children: DOB: DOB: DOB:
Occupation:
Education and Years Completed:

High School GPA: SAT(s): ACT(s):
College GPA: Degree or Major:
Future Occupational Goal:
Religious Background:
Are you adopted? No Yes
Are your parents adopted? Father Mother
Do you have knowledge of your immediate family member's medical history? (biological siblings, parents, aunts, uncles and grandparents) No Yes

 

Ethnic Origin/ Ancestry (Please be specific, i.e. Italian, Irish, German, etc.)

Father's Ethnic Background (select all that apply): African American
American Indian Brazilian Czech Dutch English French German
Indian Irish Italian Japanese Jewish Mexican Norwegian
Polish Portuguese Russian Scottish Slovakian Spanish
Swedish Welsh Yugoslavian Other:

Mother's Ethnic Background (select all that apply): African American
American Indian Brazilian Czech Dutch English French German
Indian Irish Italian Japanese Jewish Mexican Norwegian
Polish Portuguese Russian Scottish Slovakian Spanish
Swedish Welsh Yugoslavian Other:

Height:
Weight:
Right Handed Left Handed Ambidextrous
Natural Hair Color:
Hair Type: Curly Wavy Straight Balding Thin Average
Eye Color: Corrective Lenses? Yes No
Other Distinguishing Features (dimples, large eyes, etc:
Complexion: Oil Dry Normal
Skin Color: Very Fair Fair Medium Olive Dark
Body Build: Petite Small Medium Large
Contraceptive Method:
Hobbies/Interests:
Medical Problems:

No Yes

If yes, explain:
Current Medications:
Smoker: No Yes - how long?
How did you hear about this program?
Have you been an egg donor before? No Yes
If yes, how many times and when?
Are you currently an available donor at another agency or doctor's office? No Yes
Reason for donating:
Are you willing to meet the intended parents? No Yes
If you are chosen by a couple who lives outside the immediate area, are you willing to travel (all expenses paid for donor and companion)

- Outside the L.A./Orange County area, but within the State of California? No Yes

- Outside the State of California, but within the United States? No Yes
Have you spent 3 months or more cumulaively in the UK form the beginning of 1980 through the end of 1996? No Yes
Have you lived cumulatively for 5 years or more in Europe from 1980 until
present? No Yes
Have you ever been arrested? No Yes

After hitting "Submit" below, please be prepared to send a recent photo of yourself by email to sherriparker@elitefertility.com. Please no Glamour Shots.

NO APPLICATION WILL BE CONSIDERED WITHOUT A PHOTO.