Extra Conceptions Donor Application Form

First Name *

Middle Name

Last Name *

Street Address *

City *

State *

Country *

Zip Code *

Mobile Phone *

Alternative Phone Number

Email *

Alternative Email (non-college or .edu mail)

Date of Birth: *

Choose measurement system: *

Height: (I=Feet / M=centimeters) *

Weight: (I=pounds / M=kilograms)*

Race: *

Marital Status: *

Partner's First & Last Name (if applicable):

US Residency Status: *

What is your religion? If not applicable, put N/A: *

Do you have a Provincial Health Card? (Applicable in Canada): *

Do you have a valid passport?: *

Yes No

Do you have a valid driver's licence?: *

Yes No

Preferred Language: *

How did you hear about us? Please select an option and then give details in the box below.

Examples: What is your friend's name? Which Nurse Coordinator? Which radio or TV station?

The About Me section is very helpful for potential parents to get a better understanding of who you are as a person and in your own words. Please be as detailed as possible.

How would you describe yourself? What are you passionate about? What are your personal values and beliefs? Do you have a favourite color, food, season or holiday? What event has defined you? *

What do you enjoy doing with your free time? Do you have any special interests or hobbies? Do you have a special talent? Do you play a musical instrument or study another language? Do you like to play sports or be active? What are you passionate about? *

Do you have a good community of support? How is your relationship with your partner, family, and friends? What do they think about your decision to donate? *

Do you have any current goals or dreams for yourself, whether that be in your personal or professional life? What do you see for yourself in the future? How do you plan to achieve those goals? *

Willing to travel for cycle? Note, travel expenses are covered by the potential parents. *

Yes No

Are you willing to fly? Note, travel expenses are covered by the potential parents. *

Yes No

Are you open to video calls with EC and potential parents interested in your profile? *

Yes No

It is important that we help match you to the right recipient(s). Please select which you are willing to work with. *

Heterosexual Couple
Same-Sex Female Couple
Same-Sex Male Couple
Single Female
Single Male
Transgender Single Person/Couple
Interracial Couple

Please select all cycles you are open to: *

Known (Full names & emails exchanged)
Semi-Known (First names exchanged)
Anonymus

Are you open to meeting the recipients in the future? Please explain. *

Have you donated eggs before? *

Yes No

What is your highest level of Education? *

Did you attend an Ivy League School? Verification Required *

Yes No

What school did you attend? This information is kept confidential from Future Parents.

Major

GPA or Marks

Enrollment Year

Completion Year

Have you taken the following tests: SAT, ACT, MCAT, GRE, LSAT, CENEVAL, or Other?

Yes No

If yes to the above question, provide the following information for each.

SAT Year

SAT Possible Score

ACT Year

ACT Possible Score

MCAT Year

MCAT Possible Score

GRE Year

GRE Possible Score

LSAT Year

LSAT Possible Score

CENEVAL Year

CENEVAL Possible Score

Other Test Name

Other Test Year

Other Possible Score

Do you have plans on furthering your education? Please give details. *

Current Occupation *

Natural Eye Color: *

Natural Hair Color: *

Hair Type: *

Body Type: *

Complexion: *

Dominant Hand: *

Sexual Orientation: *

Parent's Ancestry: (Be specific; e.g., French, American Indian (tribe name), Irish, etc.)

Father's mother: *

Father's father: *

Mother's mother: *

Are at least one of your parents Jewish? *

Are you a registered American Indian? *

If you have any American Indian ancestry, what tribe(s) are you affiliated with? What percentage of each tribe are you? (e.g. 1/16 Cherokee, 1/2 Osage)

Religion at birth: *

Practicing: *

Yes No

Do you have tattoo(s): *

Yes No

Do you have any piercings(s): *

Yes No

What method of birth control are you using? *

How regular are your menstrual cycles? *

Have you had a Pap Smear? *

Yes No

Do you have any abnormal OBGYN problems (cysts, pap smears, etc.)? If yes, please describe. If none, please write none. *

Please list any medications you are currently taking. Make sure you include the dosage, how long you have been taking the medication(s), and the reason for taking them. *

Please list any hospitalizations or surgeries and the dates each event occurred. If you have not had any, please answer none. *

Please list any surgeries and the dates each event occurred. This includes items such as botox, fillers, body enhancements, liposuction, etc. If none, please answer none. *

If you selected any of the above, please indicate who, date of diagnosis, adn date of treatment. If none, please put N/A. *

Do you have any other medical conditions that are not listed? *

Please provide details on the conditions you've selected above. If none, please put N/A. *

Have you ever or are you currently using illegal drugs or medications not prescribed to you by your doctor? (This includes marijauana and CBD.) If yes, please elaborate. *

Were you adopted? *

Yes No

COVID-19 vaccine? *

Yes No

The section below is required if you have EVER been pregnant or have had any children. If you have never been pregnant or had any children, you can move on to the next section.

Total Number of Pregnancies:

Pregnancy #1

Date of Birth:

Eye Color

Hair Color

Sex

Birth Weight:

Please select any complications that occurred:

Miscarriage
Abortion
Stillbirth
Preeclampsia
Ectopic
Gestational Diabetes

Please list any medical conditions (Asthma, Autism, Down Syndrome, etc.)

Pregnancy #2

Date of Birth:

Eye Color

Hair Color

Sex

Birth Weight:

Please select any complications that occurred:

Miscarriage
Abortion
Stillbirth
Preeclampsia
Ectopic
Gestational Diabetes

Please list any medical conditions (Asthma, Autism, Down Syndrome, etc.)

Pregnancy #3

Date of Birth:

Eye Color

Hair Color

Sex

Birth Weight:

Please select any complications that occurred:

Miscarriage
Abortion
Stillbirth
Preeclampsia
Ectopic
Gestational Diabetes

Please list any medical conditions (Asthma, Autism, Down Syndrome, etc.)

Pregnancy #4

Date of Birth:

Eye Color

Hair Color

Sex

Birth Weight:

Please select any complications that occurred:

Miscarriage
Abortion
Stillbirth
Preeclampsia
Ectopic
Gestational Diabetes

Please list any medical conditions (Asthma, Autism, Down Syndrome, etc.)

Donor Release & Consent Agreement

Please carefully review this Agreement. If you agree with its terms and have completed the five sections of the online Application, please enter your name as directed below. Please then submit your Agreement to complete your online Application.

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1. By electronically submitting this Application I am consenting to have information contained in my Application, including my photos, audio recordings, and videos (collectively “Images”), posted on the Extraordinary Conceptions website and shared with our partner clinics and physicians. I understand that my last name, address, phone number, social security number, driver license, and last names of family members will be kept confidential and will not be posted online or shared.

2. I understand that Extraordinary Conceptions may use my Images to facilitate the matching of egg donors, surrogates, and intended parents. I hereby consent to the use of my Images and likeness in as Extraordinary Conceptions may deem appropriate for these purposes. This shall include, but is not limited to, use in electronic, digital and print media.

3. I understand that information about me that is posted online will be accessible through a password-protected “members only” section of Extraordinary Conceptions’ website and restricted database system website and will be available for review by registered surrogates and/or intended parents. Despite these safeguards, I understand that it is possible that someone visiting the website and restricted database system reviewing my Application may eventually identify me. I further understand that while Extraordinary Conceptions will make commercially reasonable efforts to safeguard my privacy, it cannot guarantee my privacy in all respects.

4. I understand that online search technology is continuously advancing. A “reverse image” search may enable users of the Extraordinary Conceptions website and restricted database system to match my photo with others online and ascertain my name and other personal information. In an effort to avoid this from happening, I understand that I should not and have not now, previously and in the future post any of the images I submit to Extraordinary Conceptions to any social media platform or anywhere else where it may be posted online. In any case, while Extraordinary Conceptions will take commercially reasonable steps to conceal my identity, I understand that I share responsibility for protecting my privacy and, as such, do hereby affirm that I have not and will not allow my Images to otherwise be posted online.

5. I affirm that the information I have provided in the application is complete, accurate and truthful. I agree to provide any additional information requested by Extraordinary Conceptions to supplement my application.

6. I understand that Extraordinary Conceptions and donors and/or intended parents will rely upon the information I provide and that Extraordinary Conceptions makes no representations or warranties, express or implied, as to the accuracy of such information. I alone am responsible for the truthfulness and accuracy of information stated on my application. I understand that I may be required to indemnify Extraordinary Conceptions for damages and all related expenses incurred in connection with any false or inaccurate information included in my Application.

7. I understand that if I am accepted into its program, Extraordinary Conceptions will use its commercially reasonable efforts to match me with potential surrogates and/or intended parents interested in an egg donation arrangement. Further, if matched with a surrogate and/or intended parents, I understand that Extraordinary Conceptions will coordinate the logistics between myself, the surrogates and/or intended parents, and the professionals retained by us. I consent to the disclosure of my personal information for the purposes of connecting me with the surrogates and/or intended parents, and related professionals, such as partner clinics and physicians, and acknowledge that I may need to complete additional agreements and releases with such parties as developments so warrant. As part of its services, Extraordinary Conceptions will assist in the procurement of a health insurance policy, or will work with outside professionals to review coverage provided under an existing health insurance policy. Such policies are evaluated for suitability for use during my intended donation cycle(s). I understand that it is my responsibility to cooperate with the specialized health insurance professionals to complete this process.

8. I understand and acknowledge that Extraordinary Conceptions will collect and deposit my compensation into a trust account and tender compensation to me upon performance under my contract with the surrogate and/or intended parents.

9. I understand that if Extraordinary Conceptions agrees to include me in its database, there is no guarantee that I will be matched with a surrogate and/or intended parents. Extraordinary Conceptions makes no promise as to the potential time frame for a match, if any. I understand that I may never be matched with a surrogate and/or intended parents.

10. I hereby acknowledge that Extraordinary Conceptions recommends that I seek medical, legal, psychological, and other relevant professional advice for guidance regarding the appropriateness of assisted reproduction, egg donation and surrogacy, the application of law to my particular situation, and any and all related concerns. Furthermore, I acknowledge that I have reviewed Extraordinary Conceptions’ statement of privacy practices accessible at https://www.extraconceptions.com/privacy-policy/ and agree to be bound by the terms thereof, as reasonably amended by Extraordinary Conceptions from time-to-time. I agree to assume full responsibility for researching and securing such advice regarding the risks and consequences of egg donation. I understand that Extraordinary Conceptions is not a medical clinic or a law office and offers no advice or opinions on the medical, legal, or psychological aspects of egg donation.

11. I understand that Extraordinary Conceptions has the absolute right to remove me from its program at any time and for any reason. I understand and do hereby expressly agree that my all of the personal information I share with Extraordinary Conceptions, including my Images, may be saved and used by Extraordinary Conceptions as follows: a) to communicate with me about Extraordinary Conceptions’ services, program offerings, news, and related surrogacy and donor information; b) to market Extraordinary Conceptions’ services and the services of such third parties that Extraordinary Conceptions reasonably determines are consistent with my interest in surrogacy and donor services and programs; c) to confirm my identity; and d) to ensure my strict compliance with the terms of this Agreement.

12. If a dispute arises out of or relates to this contract, or the alleged breach thereof, and if the dispute is not settled through negotiation, I agree first to try in good faith to settle the dispute by mediation in San Diego, California within 30 days administered under by the American Arbitration Association under its Commercial Mediation Procedures before resorting to arbitration. In the event that Extraordinary Conceptions and I are unable to agree on a mediator, a mediator shall be appointed by the named administrator. Should I fail to participate in mediation, then I give up my right to an award of attorneys’ fees and costs should this matter proceed to arbitration. All mediation-related expenses shall be split between myself and Extraordinary Conceptions.

13. Any controversy or claim arising out of or relating to this contract, or the breach thereof, that is not resolved through mediation shall be settled by arbitration in San Diego, California administered by the American Arbitration Association in accordance with its Commercial Arbitration Rules, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. All parties to mediation and arbitration shall bear their own legal fees and costs.

14. In the event of a dispute as contemplated above, Extraordinary Conceptions and I shall take all reasonable steps to preserve each other’s confidentiality and privacy rights. I agree that upon request of either party, (a) court records may be sealed and court hearings kept confidential, (b) gag orders may be issued to enforce this provision, and (c) the court may take all reasonable steps to protect our identities from disclosure to the public or the news media. Further, I agree that due to the sensitivity of our Agreement and the privacy interests of those involved, I shall not disclose to third parties any aspect of the egg donation arrangement, including the terms and conditions of this Agreement; other terms and conditions of agreements between Extraordinary Conceptions, the surrogate and/or intended parents, and me; compensation and benefits payable to me; names or other information that could lead to the identity of any party; or the substance of any dispute or disagreement between Extraordinary Conceptions, the surrogate and/or intended parents, and me.

15. I hereby release, hold harmless, and agree to indemnify Extraordinary Conceptions, including its directors, officers, agents, and employees, from and against any claims, liabilities, causes of action, damages, losses, costs, or detriments in any way related to or arising from the egg donation arrangement as contemplated herein.

16. I acknowledge that this Agreement contains the complete agreement between the parties relating to the release and consent to use my information and supersedes any prior agreement, understanding, representation, and statements between us, whether oral or written. If it is determined that a term of this Agreement is to any extent illegal, invalid, or incapable of being enforced, such term shall be excluded to the extent of such invalidity or un-enforceability; all other terms shall remain in full force and effect; and, to the extent permitted and possible, the invalid or unenforceable term shall be deemed replaced by a term that is valid and enforceable and that comes closest to expressing the intention of such invalid or unenforceable term. I hereby affirm under penalty of perjury, pursuant to the laws of the State of California, that all information contained in my Application is complete, truthful, and accurate and that I am submitting this Agreement and accepting its terms by my own volition without any coercion, duress, or undue influence.

By entering your First and Last name in the box above, you hereby accept these terms and agree to be bound by them.

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