Last Names of Adoptive Parent (s):

First Names:

Current Address:

City:

State:

Zip:

Country:

County:

Contact Numbers:

Home:______________Fax:_____________

Husband's Work:______________Pager:______________

Wife's Work:______________Pager:________________

Husband's Cell:______________

Wife's Cell:______________

E-Mail address:

E-Mail address:

Emergency Contacts:

Name:_____________________________
Relation:____________________________
Home Phone:__________________________

Name:_____________________________
Relation:____________________________
Home Phone:_______________________

Date of marriage: _____________

City and State of marriage: _____________________

Do you have and children? YES / NO If yes how many? #________

NAME

Male / Female

Date of Birth

Natural / Adopted

Resides

Do any other adults live in your home? YES / NO (i.e. parents, housekeepers, guests)

NAME Male / Female

Age:_____

Relationship to you:_____________

Do you own or rent your home?_______ Monthly Payment: $________ Amount Owed: $__________

How did you hear about our embryo adoption program? ___________________________________

Husband's Information

Full Legal Name:

Age:

Date Of Birth:

Social Security:

Place of Birth: (city, state, country)

Driver's License Number: State of Issue:

Passport Number: Are you a US Citizen?
If no, where is your citizenship?

Ancestry: (i.e. German, Irish, English, etc.)

Education:

Occupation:

Employer:

Annual Salary: $

Religion:

Active? YES / NO

Hobbies/Interests:

Physical Description:
Height

Weight

Eye Color

Hair Color

Health conditions which restrict normal daily activities or reduce normal life expectancy:__________
________________________________________________________________________________

Do you have any prior marriages? YES / NO

If yes, how many? # __________

Name of Spouse:

Date of marriage State of marriage:

County of marriage:

Date of divorce:

State of divorce:

County of divorce:

Do you have any children from a prior marriage? If yes how many? _______ YES / NO

Have you ever failed to meet your support obligation? YES / NO

Has any child ever been removed from your care due to abuse or neglect? YES / NO

Have you ever been deprived of parental rights or had your rights restricted? YES / NO

Have you ever been arrested? (Include all arrests even where charges were dismissed or never filed.) Please explain in detail on a separate sheet of paper and attach. YES / NO

Have you ever filed bankruptcy? (If yes, please explain on a separate sheet of paper and attach) YES / NO

Family Information:

Parent's Names:

Marriage Intact? YES / NO

Address:

Phone:(____)____________

Wife's Information

Full Legal Name:

Maiden:
Age:

Date Of Birth:

Social Security:

Place of Birth: (city, state, country)

Driver's License Number:

State of Issue:

Passport Number:

Are you a US Citizen?

If no, where is your citizenship?

Ancestry: (i.e. German, Irish, English, etc.)

Education:

Occupation:

Employer:

Annual Salary: $

Religion: Active? YES / NO

Hobbies/Interests:

Physical Description:

Height_______Weight_______Eye Color_______ Hair Color________

Health conditions which restrict normal daily activities or reduce normal life expectancy:__________
________________________________________________________________________________

Do you have any prior marriages? YES / NO If yes, how many? # __________

Name of Spouse

Date of marriage

State of marriage

County of marriage

Date of divorce

State of divorce

County of divorce

Do you have any children from a prior marriage? If yes how many? _______ YES / NO

Have you ever failed to meet your support obligation? YES / NO

Has any child ever been removed from your care due to abuse or neglect? YES / NO

Have you ever been deprived of parental rights or had your rights restricted? YES / NO

Have you ever been arrested? (Include all arrests even where charges were dismissed or never filed.) Please explain in detail on a separate sheet of paper and attach. YES / NO

Have you ever filed bankruptcy? (If yes, please explain on a separate sheet of paper and attach) YES / NO

Family Information:

Parent's Names:

Marriage Intact? YES / NO

Address:_____________________________

Phone: (_____)________________

Infertility History:

Please give us your complete fertility history. (include doctors, successes, failed attempts, etc.)
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Number of Pregnancies:
Full Term

Premature

Aborted Miscarried

Tell us what led you to select embryo adoption as opposed to other alternatives? __________________________________________________________________________________________________________________________________________________________________________________________________________________

Preferences regarding embryo:
Please indicate which racial / ethnic characteristics you prefer in a genetic family.(indicate ½ or ¼ where a mix is acceptable:
Caucasian_____ Hispanic_____ Middle Eastern_____ Asian_____ Native American_____ Black_____
Any Race or combination_____

Are you open to embryos created by the use of a donor (either egg donor or sperm donor)? YES/NO

Desired contact following adoption of embryos (e.g., photos, letters, phone contact, visitation, etc.):
__________________________________________________________________________________________________________________________________________________________________________________________________________________

Fertility Doctor / Clinic Information:

Facility Name:

Doctor's Name:

Contact Person / Nurse:
Street Address:_________________________
Suite #:

City:__________________State:_____Zip:_________

Office Phone #:(____)__________

Office fax #:(____)__________

PERMISSION to DISCLOSE:

When discussing you with a genetic couple we will refer to you by your first names. Please indicate that you understand this and therefore give us permission to do so by signing you name(s) below.

X_________________________________

X_________________________________
Husband's Signature