Embryo Adoption Application Form

1Recipient 1
2Employment History
3Criminal History
4Family History
5Medical History
6Donation Preferences
7Embryo Donation Program Agreement

Today's Date

Sun Mon Tue Wed Thu Fri Sat

First Name

Last Name

Preferred Name

Email

Mobile Phone

Home Phone

Country

Street Address

Unit #

City

State/Province

Zip/Postal Code

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Gender

Relationship Status

What is your Citizenship?

Do you have preferred pronouns?

Referred By

Recipient (1), what is your occupation?

(If Applicable)

Recipient (2), what is your occupation?

Do either of you have a criminal record?

Have you ever

(check all that apply)

Been charged with neglect or abuse

Filed for bankruptcy

Been arrested

None Of These

Other

We require each Intended Parent to provide us with a criminal record check from their home country before signing a legal contract with the Embryo Donors. Do you consent to this?

Yes

Recipient (1)

What is your ancestry?

Recipient (2)

What is your ancestry?

Do either of you currently have any children?

If so, please include name, age & gender.

Do you or your partner have any known medical conditions?

Why are you interested in Embryo Donation?

Are you seeking parenthood through other means at this time?

How do you prefer to be contacted?

Are you currently with or do you have a preference to a Fertility clinic?

Are you willing to travel to have an Embryo Transfer?

Yes

Unsure

How many children are you hoping to have?

What is the minimum # of embryos you hope to receive?

Please take into consideration the above when answering this question.

Do you wish for the embryos to be PGS/PGT tested?

Have you applied with any fertility agencies in the past?

Do you understand the Assisted Reproductive laws in the country you plan to proceed with the Embryo Transfer?

What is your timeline?

Please specify when you hope to get started

Do you want your Embryo Donor Family to be willing to be contacted when your children reach maturity (usually age 16-21)?

Would you be willing to give yearly updates to the embryo donor family?

Do you want to stay in touch with the embryo donor family until the child reaches legal age?

What is most important to you in an embryo donor family?

Please select all applicable

Willing to Give/Receive Updates Before Donor-Conceived is 18

Close Relationship between families

Embryo quality

Personality

Physical Appearance

How do you envision ongoing contact? What would you like your relationship with your embryo donor(s) after the process to look like?

How you approach this is unique for every person and we are happy to help guide you along the way.

1. It is my/our desire to enter into an embryo donation arrangement with the embryo donor(s) in an attempt to become parents. I understand the requested or provided information is needed to determine eligibility for the "Her Helping Habit Embryo Donation Program" and consulting services. I authorize Her Helping Habit to release or obtain information related to a potential embryo donation transfer. This information may be used only for the purpose of coordinating Embryo Donation efforts and/or evaluation/assessment.

2. I understand that I need to keep information received about potential embryo donors confidential. I will not use any technology or other methods to seek out a donor I have received information on from HHH, i.e. reverse image searching. I will not use any means whatsoever to contact any donors without first going through Her Helping Habit prior.

3. This consent is automatically renewable and does not need to be repeated when information is given on multiple embryo donors over an unlimited time period. I understand if I decide to go ahead with an embryo donor in the Her Helping Habit program, I will be sent an invoice to hire the Consultant for support services for myself and the embryo donor throughout the duration of this journey.

4. I consent to Her Helping Habit creating a Recipient profile on my behalf to be shared with my potential embryo donor. Therefore, I acknowledge and agree that I consent to have applicable information in my application and a photograph shared with any and all embryo donors (my name, address, and other identifying information will be kept confidential).

5. I consent to Her Helping Habit doing a background check with a third party to ensure I do not have a criminal record as indicated on my application. Therefore, I acknowledge and agree that I consent to have applicable information in my application shared with a trusted third-party background check provider and searched within the RCMP National Repository of Criminal Records. U.S. citizens and International clients may be asked to present a “certificate of good conduct”, “lack of a criminal record" or similar document instead. You understand that this is a name-based check that does not ask for fingerprints and is not a Vulnerable Sector Check.

6. I am aware that Her Helping Habit may use photographs, audio and digitized videos to facilitate the partnering process between Embryo Donors and Recipient Couples. If I do not want to share a photo of myself, I will inform my coordinator. I acknowledge this may limit the number of embryo donors available to me. I understand I have the right to see any information I release on myself at any time, and I will be required to submit a Recipient profile with Her Helping Habit.

7. Should any dispute arise between myself and Her Helping Habit with the donor services provided or any other dispute regarding my participation in this program the dispute shall first be submitted to the agency for resolution prior to utilizing any other dispute resolution options, including court. All Parties shall bear their own legal fees and costs in such case. Further, Her Helping Habit and I agree that in the event of a dispute, we will not participate in any Internet chat sites, Facebook groups online services, and the like (e.g., www.surromomsonline.com) and participate in any “chats, “conversations,” or “discussions, or “post” any written statements and/or commentary concerning any aspect of this arrangement, including, without limitation: terms and conditions of this Agreement between Her Helping Habit or between myself and the embryo donor; reimbursements; or the substance of phone or video call with Her Helping Habit, and dispute or disagreement with Her Helping Habit.

8. I understand that Her Helping Habit is not a medical clinic or a legal office and offers no advice or opinions on embryo donation's medical or legal aspects. I am aware that laws regarding egg donation vary from country to country, and I accept full responsibility for researching the legal implications of the act I am considering. I hereby release and discharge Her Helping Habit, their employees and representatives from all liability and all manners of action, suits, causes of actions, proceedings, debts, claims, and demands whatsoever in law or equity resulting from my/our decision to engage in embryo donation and any adverse consequences or damages that may result from my/our involvement with the embyo donation process. I hereby agree to indemnify, defend and hold harmless Her Helping Habit their employees and representatives against liability as well as against loss, and for any and all costs incurred defending any complaints, actions or claims.

9. Her Helping Habit makes no representations, warranties or guarantees regarding the potential embryo donor. I understand that Her Helping Habit services do not guarantee a partnership with an embryo donor and/or the live birth of a child.

10. I swear that all of the information contained in my application and this release is complete, truthful and accurate. By submitting this agreement and accepting its terms, I am doing so under my own volition without any coercion, duress or undue influence.

Recipient 1

By signing below, I agree to the terms.

IP 1: Print Full Name

IP 1: Signature

Please draw your signature

Clear

Is there a second Recipient?