Egg Donors Sign up form for new Egg Donors Step 1 of 5 0% Contact InformationFirst Name*Last Name*Street Address*City*State*Zip Code*Date of Birth* Phone Number*Best Time to Contact (Check all that apply)* Afternoon Early Morning Evening Late Night Mid Day Email Address (will be your username)* Enter Email Confirm Email Password* Enter Password Confirm Password Strength indicator Physical AttributesUpload a Photo of Yourself*Age*Please enter a value between 18 and 65.Weight (lbs.)*Height*Height4'10"4'11"5'0"5'1"5'2"5'3"5'4"5'5"5'6"5'7"5'8"5'9"5'10"5'11"6'0"6'1"6'2"6'3"6'4"Eye Color*-- select a Eye Color --BlueBrownGreenGreyHazelOtherNatural Hair Color*-- select a Hair Color --BlackBlondeBrownDark BlondeDark BrownLight BrownOtherRedSkin Tone*-- select a Skin Tone --DarkExoticLightMediumNormalTanEthnicity (Select up to 5)*Adopted-UnknownAfricanAfrican AmericanAlbanianAmericanAmerican IndianArabArmenianAsianAustrianBelgianBrazialianBritishCambodianCanadianChineseColombianCroationCubanCzechDanishDominicanDutchEgyptianEnglishEquadorianEuropeanFilipinoFinnishFrenchGermanGreekGuatemalanHaitianHawaiianHispanicHonduranHungarianIranianIrishIsraeliItalianJamaicanJapaneseKoreanLatin AmericanLebaneseLithuanianMexicanNicaraguanNigerianNorthern EuropeanNorwegianOtherPakistaniPeruvianPolishPortuguesePuerto RicanRomanianRussianSalvadoranScandinavianScottishSerbianSlavicSlovakSpanishSwedishSwissSyrianTaiwaneseThaiTurkishUkranianVietnameseWelschWest IndianWestern EuropeanYugoslavianRace*African AmericanAmerican Indian / Alaska NativeAsianCaucasianHispanic / LatinoOtherPacific Islander Personal Health InformationDo you use Birth Control*YesNoIf yes, what type of Birth Control?* Smoker*YesNoIf yes, how many cigarettes do you smoke and how often?* Do you consume alcohol?*NeverOnce a monthSociallyOnce a weekMore than once a weekEvery dayDo you use illegal drugs?*YesNoDonation ExperienceWhy are you considering becoming an egg donor?* Have you donated before?*YesNoIf yes, how many times and what was the outcome?* What is your desired compensation?*Are you willing to travel for egg retrieval (at parents expense)?*YesNoConsider open ovum donation process? (check all that apply)*No, I want to remain anonymousYes, consider meeting the Intended ParentsYes, consider meeting the child/children once of ageYes, consider sharing communication and picturesYes, would want to know the outcome of the donation cycleDo you have children?*YesNoIf yes, how many and what ages?* Barring partner infertility, how long did it typically take you to conceive?< 6 mos.6 - 12 mos.> 12 mos.Genetic Testing Completed Please indicate if you have been tested for the following:Cystic Fibrosis*YesNoSickle Cell Anemia*YesNoHereditary Hearing Loss*YesNoBeta Thalassemia*YesNoMultiple Schlerosis*YesNoTay-Sachs Disease*YesNoMedical HistoryDo you take any medication?*YesNoIf yes, please list all medications* Do you or someone in your immediate family have/had a medical condition or previous surgery?*YesNoIf yes, please list any conditions, significant birth defects, diseases and/or surgeries.* Do you use/need corrective lenses?*YesNoDo you have Health Insurance Coverage?*YesNoIf yes, who is your provider?*Family HistoryPlease list the age and cause of death for any Parents, Siblings, First Cousins, Aunts/Uncles or Grandparents who have passed away.* Education InformationIQ Level*Please enter a value between 50 and 200.College Education*YesNoG.P.A*Please enter a value between 1 and 4.ACT ScorePlease enter a value between 1 and 36.SAT TypeOldNewSAT ScorePlease enter a value between 0 and 2400.Select highest completed college education*-- select a Education --College GraduateCompleted Associate's DegreeCurrently Enrolled in CollegeCurrently Enrolled in Doctorate SchoolCurrently Enrolled in Graduate SchoolDoctorate / Ph.D.Masters DegreeVocational / Grade School GraduateSelect highest completed level of education*-- select a Highest Level Education --Please list College name, year graduated, degree major, additional awards or recognitions.* Personal InformationAre you currently employed full time?*YesNoIf yes, what is your occupation?*If no, what was your last job?*Are you a U.S. citizen?YesNoWhat is your religious orientation?*Do you have a criminal record besides minor traffic tickets?*YesNoIf yes, please explain below* Please tell us about yourself (exercise, hobbies, interests, aspirations, etc.).* How did you hear about us?*ReferralWeb / Internet SearchTV / Radio AdvertisementEmail CampaignOtherIf referred, who can we thank for the referral?*If you did a search, what did you search for?*If other, please explain* Required Questions The FDA requires that we ask you the following questions. Your complete honesty and accuracy are essential and appreciated.In the past 12 months, have you had a blood infusion?*YesNoHave you ever had a blood transfusion in England, Wales, Scotland, Northern Ireland, Channel Islands, Isle of Man, Gibraltar or Falkland Islands?*YesNoIn the past 12 months, have you had sexual intercourse with any person who has ever received human-derived clotting factor concentrates?*YesNoHave you ever received human pituitary-derived growth hormone or beef-derived insulin?*YesNoIn the past 12 months, have you had any tissue transplantation or ever had a transplantation of cornea (covering of the eye) or dura mater (covering of the brain)?*YesNoHave you or any of your blood relatives ever had Creutzfeld-Jakob disease or been told you are at risk for it?*YesNoIn the past 5 years, have you used injectable intravenous drugs for non-medical purposes (botox, collagen injections are okay)?*YesNoIn the past 12 months, have you had sexual intercourse with someone who has used intravenous drugs?*YesNoIn the past 12 months, have you had sexual intercourse with a man who had sexual intercourse with another man?*YesNoIn the past 12 months, have you had sexual intercourse with any person known or suspected to have HIV, clinically active Hepatitis B or Hepatitis C?*YesNoIn the past 5 years, have you ever had sexual intercourse for money or drugs?*YesNoIn the past 12 months, have you been exposed to known or suspected HIV, Hepatitis B, and/or Hepatitis C through infected blood by innoculation (i.e. needle stick) or through contact with an open wound or mucous membrane such as eye or mouth?*YesNoIn the past 12 months, have you been held in jail, prison or a correctional facility for more than 72 hours?*YesNoIn the past 12 months, have you had any body piercings, ear piercings (using a needle), tattoos, or accupuncture in which shared instruments are known to have been used?*YesNoHave you ever been diagnosed with clinical, symptomatic or viral Hepatitis?*YesNoIn the past 2 months, have you had a smallpox vaccination or have you had contact with the smallpox vaccination site of another person?*YesNoIn the past month, have you had direct contact with a person with or suspected to have SARS or West Nile Virus?*YesNoIn the past 7 days, have you had a fever with a headache?*YesNoIn the past 14 days, have you had an open sore or infection?*YesNoHave you, your partner or any member of your household ever had a transplant or medical procedure that involved being exposed to live cells, tissues or organs from an animal?*YesNoIn the past 28 days, have you had a temperature °100.4 F, cough, shortness of breath, difficulty breathing, hypoxia or x-rays, indicating pneumonia or acute respiratory distress syndrome?*YesNoPlease provide the number of sexual partners you have had in the past 6 months.*I understand that I must not have had any vaccination within one month of egg donation.*YesNoCommentsThis field is for validation purposes and should be left unchanged.