IP Application Form

1Intended Parent 1
2Intended Parent 2
3Employment History
4Criminal History
5Family History
6Medical History
7Donation Preferences
8Egg Donor 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

Are you going through this journey with a spouse/partner?

Intended Parent (1), what is your occupation?

(If Applicable)

Intended Parent (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

Intended Parent (1)

What is your ancestry?

Intended Parent (2)

What is your ancestry?

Do either of you currently have any children?

If so, please include name, age & gender.

Are either of you religious?

Do you or your partner have any known genetic conditions?

Are either of you infertile?

If you are a woman, have you miscarried?

If you are a woman, have you had a premature birth?

What procedures have you tried so far?

How do you prefer to be contacted?

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

For how long have you been trying to become a parent?

How many children are you hoping to have?

How many embryos do you hope to create?

Please take into consideration the above when answering this question. This information is used for shared donor cycles. This option may be suggested to you if you do not require the number of excess embryos and other recipients are working with the same clinic.

Do you wish to have your embryos PGS/PGT tested?

Have you applied with any surrogacy or egg donation agencies in the past?

Do you understand the Assisted Reproductive laws in the country you plan to undergo treatment?

What is your timeline?

Please specify when you hope to get started

Do you want your Egg Donor to be willing to be contacted when your children reach maturity (usually age 18-21)?

Would you be willing to give yearly updates to your egg donor?

Do you want to stay in touch with your Egg Donor until the child reaches legal age?

What is most important to you in a donor?

Please select all applicable

Personality

Proven Egg Donor

Physically Resembles Me

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

What is your total budget for a donor's reimbursement?

This includes personal and travel expenses. Therefore, how you answer may limit donors to you based on your location, their location, and associated costs.

How do you envision an open cycle? what would you like your relationship to look like with your egg donor after the process?

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

Please write any other preferences you have in an egg donor.

We will do our best to match you accordingly.

Please include anything specific you would like to be shared with your chosen egg donor:

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

2. I understand that I need to keep information received about potential egg 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. I will not share the free database link password provided to me to access donor profiles (free or paid) with anyone other than the Intended Parents on this document.

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

4. I consent to Her Helping Habit creating an Intended Parent profile on my behalf to be shared with my potential egg donor. Therefore, I acknowledge and agree that I consent to have applicable information in my application and a photograph shared with my chosen egg donor (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 a 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 Egg 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 egg donors available to me. I understand I have the right to see any information I release about myself at any time, and I will be required to submit an Intended Parent profile if I choose to go ahead with an egg donor suggested by Her Helping Habit.

7. I understand if I want to review a donor’s complete, detailed profile, Her Helping Habit will send me an invoice for $250.00 as an intake fee. This is to consult with Her Helping Habit. If I choose to go ahead with an egg donor in the Her Helping Habit database, a further $2000.00 is required to request this donor and remove her availability from the HHH database. If I do not choose a donor in Her Helping Habit's program these amounts are a non-refundable administration fee. I understand there are no refunds for these services

8. 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 before 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 egg donor; reimbursements; or the substance of phone or video call with Her Helping Habit, and dispute or disagreement with Her Helping Habit.

9. I understand that Her Helping Habit is not a medical clinic or a legal office and offers no advice or opinions on egg 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 egg donation and any adverse consequences or damages that may result from my/our involvement with the egg 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.

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

11. 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.

Intended Parent 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 Intended Parent?