Surrogate Application "*" indicates required fields 123456789101112131415 General InformationName* First Middle Last Nickname (if applicable) Marital Status* Single Married Long Term Relationship Divorced Maiden Name* Email* Cell Phone*Alternate Phone*Date of Birth* MM slash DD slash YYYY Age*Thank you for your interest in becoming a surrogate with Shining Light Baby. Unfortunately, we are unable to proceed with your application at this time as our minimum age requirement is 21. If you would like to apply when you reach the age requirement, we’d love to revisit your application. We appreciate your understanding and wish you the best on your journey!Thank you for your interest in becoming a surrogate with Shining Light Baby. Unfortunately, we are unable to proceed with your application at this time as our age limit is 42 years old. We appreciate your understanding and wish you the best on your journey!Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you plan on moving in the next 2 years?* Yes No To which state?*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingLength of Time at Current Address* Driver's License Number* Driver's License State of Issue*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDriver's License Expiration Date* MM slash DD slash YYYY Nearest Airport* Emergency Contact Person* Emergency Contact Phone*What is the Emergency Contact's relationship to you?* Aside from your child/ren and spouse/partner, is there anyone else living in your home?* Yes No Please list the names and ages of the other people living in the home*Who will be your primary source(s) of emotional support during and after your Surrogacy journey?* Are you or your children currently receiving any government assistance such as subsidized or free health care insurance, WIC, or food stamps?* Yes No Please provide details, including date you started receiving benefits* Personal InformationHeight*Select4' 8"4' 9"4' 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"Weight*Select90 lbs91 lbs92 lbs93 lbs94 lbs95 lbs96 lbs97 lbs98 lbs99 lbs100 lbs101 lbs102 lbs103 lbs104 lbs105 lbs106 lbs107 lbs108 lbs109 lbs110 lbs111 lbs112 lbs113 lbs114 lbs115 lbs116 lbs117 lbs118 lbs119 lbs120 lbs121 lbs122 lbs123 lbs124 lbs125 lbs126 lbs127 lbs128 lbs129 lbs130 lbs131 lbs132 lbs133 lbs134 lbs135 lbs136 lbs137 lbs138 lbs139 lbs140 lbs141 lbs142 lbs143 lbs144 lbs145 lbs146 lbs147 lbs148 lbs149 lbs150 lbs151 lbs152 lbs153 lbs154 lbs155 lbs156 lbs157 lbs158 lbs159 lbs160 lbs161 lbs162 lbs163 lbs164 lbs165 lbs166 lbs167 lbs168 lbs169 lbs170 lbs171 lbs172 lbs173 lbs174 lbs175 lbs176 lbs177 lbs178 lbs179 lbs180 lbs181 lbs182 lbs183 lbs184 lbs185 lbs186 lbs187 lbs188 lbs189 lbs190 lbs191 lbs192 lbs193 lbs194 lbs195 lbs196 lbs197 lbs198 lbs199 lbs200 lbs201 lbs202 lbs203 lbs204 lbs205 lbs206 lbs207 lbs208 lbs209 lbs210 lbs211 lbs212 lbs213 lbs214 lbs215 lbs216 lbs217 lbs218 lbs219 lbs220 lbs221 lbs222 lbs223 lbs224 lbs225 lbs226 lbs227 lbs228 lbs229 lbs230 lbs231 lbs232 lbs233 lbs234 lbs235 lbs236 lbs237 lbs238 lbs239 lbs240 lbs241 lbs242 lbs243 lbs244 lbs245 lbs246 lbs247 lbs248 lbs249 lbs250 lbs251 lbs252 lbs253 lbs254 lbs255 lbs256 lbs257 lbs258 lbs259 lbs260 lbs261 lbs262 lbs263 lbs264 lbs265 lbs266 lbs267 lbs268 lbs269 lbs270 lbs271 lbs272 lbs273 lbs274 lbs275 lbs276 lbs277 lbs278 lbs279 lbs280 lbs281 lbs282 lbs283 lbs284 lbs285 lbs286 lbs287 lbs288 lbs289 lbs290 lbs291 lbs292 lbs293 lbs294 lbs295 lbs296 lbs297 lbs298 lbs299 lbs300 lbsBMIThank you for your interest in becoming a surrogate with Shining Light Baby. Unfortunately, we are unable to proceed with your application at this time due to BMI requirements. If your circumstances change in the future, we encourage you to reach out, and we’d love to revisit your application. We appreciate your understanding and wish you the best on your journey!HiddenHeight (old)* HiddenWeight (old)* Race* Religion* Highest Level of Education Completed* High School or GED Vocational or Trade School Some College Associate Degree Bachelor's Degree Graduate or Professional Degree Do you speak any other languages besides English?* Yes No Please list any other languages you speak/write:* Have you ever lived outside of the U.S.?* Yes No Please list dates and locations* Have you traveled out of the country within the last year?* Yes No Please list locations of travel* Do you have any plans to travel out of the country any time in the near future?* Yes No Please list dates and locations of travel* Have you had Covid-19 Vaccination?* Yes No Are willing to have Covid-19 Vaccination?* Yes No Employment InformationAre you currently employed?* Yes No Employment DetailsWhat is your occupation?* How long have you been working at your current employer?* How many hours do you work per week?* What hours of the day do you work?* What is your yearly salary or hourly wage?* Do you have health insurance?* Yes No Does your employer offer a short term disability plan?* Yes No I'm not sure Are you enrolled in the short term disability plan?* Yes No I'm not sure General Health HistoryHave you ever experienced any major or minor medical issues or illnesses in your life so far?* Yes No Please specify the issue/illness and date(s)*Have you ever had any major or minor surgery?* Yes No Please specify the surgery and date(s)*Have you ever been hospitalized for any other reason besides childbirth?* Yes No Please specify the reason(s) for hospitalization and date(s)*Are you presently taking any prescription or over-the-counter medications?* Yes No Please specify name(s) of medication(s) and reasons for use* Have you ever been tested for HIV/AIDS?* Yes No Please share most recent date of testing and results* Have you ever been diagnosed with an STI/STD?* Yes No Please share details of STI/STD and date(s) of treatment* Have you ever seen a mental health professional (psychologist, social worker, counselor, or psychiatrist)?* Yes No Please share reason(s) and date range(s):* Are you currently taking, or have you ever taken medication for a psychiatric issue, including anxiety and / or depression?* Yes No Please provide the name of the medication(s) and the date range of usage* Please explain reason you take medication(s)* Have you ever experienced postpartum depression?* Yes No Please provide details and date range* Reproductive HistoryHow many times have you been pregnant?*Include all pregnancies, including those that were terminated or ended in miscarriage.Please enter a number from 1 to 6.How many children have you delivered?*Include any births, whether your own children or surrogate pregnancies.Please enter a number from 1 to 6.Have you ever been an egg donor?* Yes No Please provide details about your egg donation(s)* Have you ever been a surrogate?* Yes No Please provide details about your surrogacy journey(s)* Have you ever done fertility treatment to achieve pregnancy?* Yes No Fertility treatments were to conceive* My own children Surrogate pregnancy Have you ever had a miscarriage?* Yes No Please list date(s) and weeks gestation at time of miscarriage*Have you ever had an abortion?* Yes No Please list date(s) and details*Have you ever delivered prematurely (before 36 weeks)?* Yes No Please list date(s) and details*Have you ever had a baby or child pass away?* Yes No Please list date(s) and details*Have you ever experienced any of the pregnancy or delivery complications below?*Check all that apply. Pre-term labor Cerclage Excessive bleeding or hemorrhage Ectopic pregnancy Gestational diabetes Pregnancy induced hypertension Placenta previa IUGR Pre-eclampsia Shortened cervix Other None Please explain and provide dates*What is your current form of birth control?*Check all that apply Birth control pills Condoms Diaphragm Tubal ligation Partner vasectomy Sexual abstinence IUD Nuva ring Implanon/Nexplanon Norplant Essure None Other Please specify other* Do you have regular menstrual cycles?* Yes No What was the start date of your most recent menstrual period?* MM slash DD slash YYYY What was the last day of your most recent menstrual period?* MM slash DD slash YYYY Your Surrogacy HistoryHow many transfers did you have to achieve pregnancy?How many embryos were transferred at each attempt?*Name of fertility center/doctor to complete embryo transfer* Did you have any complications with estrogen or progesterone?* Yes No Please explain* Did your lining respond appropriately to the medication protocol?* Yes No Please explain* Please share any additional details regarding your previous journey(ies); i.e., did you enjoy your experience?*What type of relationship did you have with the Intended Parent(s) and are you still in contact?*Have you shared your plans to do another journey with any family or friends?* Yes No What was their reaction?* Please describe your feelings carrying and delivering a baby/babies that was/were not your own.* Your Delivery HistoryChild 1*GenderDelivery DateMonths to ConceiveWeeks at DeliveryMethod of DeliverySurrogacy or Your Own?Child 2*GenderDelivery DateMonths to ConceiveWeeks at DeliveryMethod of DeliverySurrogacy or Your Own?Child 3*GenderDelivery DateMonths to ConceiveWeeks at DeliveryMethod of DeliverySurrogacy or Your Own?Child 4*GenderDelivery DateMonths to ConceiveWeeks at DeliveryMethod of DeliverySurrogacy or Your Own?Child 5*GenderDelivery DateMonths to ConceiveWeeks at DeliveryMethod of DeliverySurrogacy or Your Own? About Your ChildrenHow many children do you have?*Please enter a number from 1 to 6.Do you have custody of all your children?* Yes, Full Yes, Partial No Please explain reason for partial/no custody* Do any of your children have a disease, disorder, or health issue?* Yes No Please provide details of any issues* Do any of your children have psychological concerns or diagnosis?* Yes No Please provide details of any psychological concerns or diagnosis* Are you currently breastfeeding?* Yes No When do you plan on weaning?* Spouse/Partner InformationSpouse/Partner's Name* First Middle Last Spouse/Partner Date of Birth* MM slash DD slash YYYY Spouse/Partner's Phone*Spouse/Partner's Email* Does your spouse/partner live with you?* Yes No Please explain*Spouse/Partner's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Spouse/Partner's Driver's License Number* Spouse/Partner's Driver's License State of Issue*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingSpouse/Partner's Driver's License Expiration Date* MM slash DD slash YYYY Is your spouse/partner currently employed?* Yes No Spouse / partner’s occupation* How long has spouse / partner been with current employer?* Spouse/partner's yearly salary or hourly wage* Has your spouse/partner ever been diagnosed with an STI/STD?* Yes No Please share details of STI/STD and date(s) of treatment* Does your spouse/partner have any history of psychological issues or mental illness?* Yes No Please explain spouse/partner psychological issues or mental illness* Is your spouse/partner currently taking medication for a psychiatric issue, including anxiety and/or depression?* Yes No Please provide the name of the medication(s) and the date range of usage* Please explain reason spouse/partner takes medication* Is spouse / partner aware of your plans to become a Surrogate?* Yes No Do they support your decision to become a Surrogate?* Do they have any concerns?* Has your spouse/partner ever experienced any of the following?* Declared bankruptcy Been delinquent with child support payments Received a DUI/DWI Been accused and/or convicted of abuse towards a child or adult Been arrested Been in a substance abuse program Been convicted of a felony Other None of the Above Please share details and dates* Legal InformationDo you have any past, current or ongoing open legal cases?* Yes No Please share details and dates*Have you ever experienced any of the following?* Declared bankruptcy Been delinquent with child support payments Received a DUI/DWI Been accused and/or convicted of abuse towards a child or adult Been arrested Been in a substance abuse program Been convicted of a felony Other Please share details and dates* Personal ReferencesReference #1 Name* First Last Reference #1 Phone*What is your relationship to Reference #1?* Reference #2 Name* First Last Reference #2 Phone*What is your relationship to Reference #2?* Personality, Interests & LifestylePlease tell us about your personality; describe your likes/dislikes, strengths and weaknesses, and anything further that will give some additional insight into who you are.*Please describe a typical day in your life.*What do you do for fun?*Please state your life philosophy in no more than a short paragraph.*Please describe the food you eat on a typical day and food you enjoy on special occasions. What is your favorite? Please specify if you practice any food model such as veganism, vegetarianism, the keto diet, etc.*Have you ever had an eating disorder?* Yes No Please share details*Do you exercise?* Yes No How often and exercise description (i.e., jogging, swimming, treadmill, jazzercize, Zumba, yoga, etc).*Have you ever used any illegal drugs?* Yes No Please share details and dates of use* Have you ever or do you currently smoke cigarettes or vape?* Yes No Please share details and dates of use* Are you willing to refrain from smoking any form of tobacco, including ingesting marijuana, for the entire duration of your Surrogacy process?* Yes No Does anyone who lives in your home smoke any tobacco products or vape?* Yes No Please describe details such as type of tobacco and if they smoke in the house.* Do you drink alcohol?* Yes No How often? Please list the number of times weekly, monthly, or yearly to give us a general idea.* Are you willing to refrain from drinking any amount of alcohol for the entire duration of your Surrogacy process?* Yes No Matching PreferencesHow much are you requesting for base compensation?*As a Surrogate, you have the option of matching with all different types of Intended Parents. Below please find listed all of the potential scenarios and check the options you would consider:* Heterosexual married couple Heterosexual unmarried couple Same sex male couple Same sex female couple Single Intended Father Single Intended Mother International Intended Parents Domestic Intended Parent(s) Non-English speaking Intended Parent(s) Intended parent(s) 50 years of age or older HIV+ Intended Parent(s) Intended Parents who are doing, or who would like to do, two surrogacy journeys simultaneously Intended Parents who are hoping to work with a Surrogate who will consider a sibling journey If you have any preferences in regards to the above, even if you will consider the others, please list them here:*Please describe your ideal intended parent match*Are you willing to travel to a fertility center for a medical screening appointment (typically one overnight stay) and the embryo transfer (typically two overnight stays)?* Yes No Please check the options below with which you are comfortable*Check all that apply. Air Travel Automobile Travel How many embryos are you open to transferring?* One Two One or Two Are you open to carrying twins?* Yes No Are you open to carrying triplets, in the event an embryo were to split?* Yes No Would you reduce a multiple pregnancy if requested by the Intended Parents and the doctor felt it was medically safe/advisable?* Yes No Would you agree to terminate the pregnancy if requested by the Intended Parents and the doctor felt it was medically safe?* Yes No, I would not terminate for any reason Under what circumstances?*Check all that apply. I would agree to terminate if the baby was diagnosed with Down Syndrome I would agree to terminate if the baby was diagnosed with a life-threatening condition or a condition that would seriously impact quality of life Are you willing to have an amniocentesis if requested by the Intended Parent(s) and the doctor advised it was medically safe?* Yes No Please describe your ideal Surrogate birth experience*How do you think you will feel about carrying and delivering a baby that is not your own?*Have you shared your plans for starting this surrogacy journey with any family or friends?* Yes No What was their reaction?* Please indicate the type of relationship you envision with your Intended Parents by checking the below that most accurately describe your feelings at this time.* I am open to whatever unfolds naturally, if we become friends that’s great but if we are only in contact pertaining to Surrogacy specific matters, I am fine with that as well. Same with staying in contact afterwards, if it happens I’m open but it is not a requirement for me. I am really hoping to form a nice relationship with my Intended Parent(s) throughout the pregnancy and to keep them included in all aspects. It is my hope that we at least exchange holiday cards or maintain a minimal level of contact after the delivery, even if once a year via text, but aside from this, it’s up to the Intended Parents and I’m flexible. I am really hoping to form a close relationship and bond with my Intended Parent(s) and would like to remain in touch and long-term friends after delivery too. If it did not turn out this way, I would be disappointed. I realize that at this time we do not know each other and nobody knows for sure how it will turn out, but I am going into this process with the hope of a friendly and lost lasting relationship. I will certainly provide updates regarding all doctor appointments and pregnancy related issues, but I’m not necessarily interested in becoming close friends with my Intended Parent(s). I would not mind at all if after this journey was over and the baby was born we eventually discontinued contact. I honestly have no idea what to expect as I cannot form an opinion regarding this until I know the Intended Parent(s) with whom I will be matching. I think once I match and the journey is in process, I will be able to envision this more clearly. Other Would you be comfortable with your Intended Parent(s) coming to your OB appointments and/or ultrasound appointments?* Yes No Would you be comfortable with your Intended Parents joining you in the delivery room?* Yes No Provided they are “G rated,” will you be comfortable with your Intended Parent(s) taking photos during the birth?* Yes No Would you be comfortable with your Intended Parents taking photos of you during the pregnancy or sharing belly pictures with them?* Yes No As part of your application, we kindly ask you to complete the following prompts to help us create a personalized letter that will be shared with intended parents. This letter is an important part of the matching process, allowing intended parents to get to know you better and understand your motivations, values, and personality. Your thoughtful responses will help us ensure a great match and foster a strong, supportive relationship throughout the surrogacy journey. Please take your time and provide as much detail as you feel comfortable sharing. Write a brief introduction note to potential intended parents.*Include your state of residence, your family situation, and your occupation. Do not include any identifying details, like your last name or city of residence.In my daily life, I enjoy...*Describe your lifestyle and any hobbies you may participate in.I decided to become a surrogate because...*I envision my relationship with my IPs to be…*I want intended parents to know that...* Your Surrogacy JourneyHow did you hear of Shining Light Baby?* Were you referred by someone?* Yes No Please let us know their name so we can thank them!* Have you applied to any other surrogacy programs?* Yes No Please list agency name(s)* What is your acceptance status at each of the agencies listed?*Please share reasons for not being accepted*UntitledFirst ChoiceSecond ChoiceThird Choice