Embryo Donor Application

1Parent 1
2Parent 2
3Employment History
4Criminal History
5Family History
6Embryo Information
7Donation Preferences
8Embryo 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

Did you create your embryos 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

Parent (1)

What is your ancestry?

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, your partner or children have any known genetic conditions?

If, yes, please tell us which one(s):

How Many Embryos Do You Have?

When were the Embryos Created?

Where are your Embryos Stored?

Did you use Donated Gametes (sperm and/or egg)?

How old was the Egg Source at the time of creation?

How old was the Sperm Source at the time of creation?

Were your embryos PGS/PGT tested?

Why do you want to donate your embryos?

Would you be willing to be a known embryo donor? This means your identities are exchanged between you and the recipients to allow the exchange of necessary information for both of you presently or in the future. Sometimes, these types of donations can develop into friendships organically.

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

Would you like to receive yearly updates from your recipient family?

What is most important to you in recipients?

How do you envision a known donation? What would you like your relationship to look like?

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

Do you understand the Assisted Reproductive laws in Canada?

1. Consent to Participate I/we, the undersigned, hereby acknowledge our intention to participate in the Her Helping Habit Embryo Donation Program as "Donors". All information I/we have supplied in the application is truthful, complete, and accurate to the best of my/our knowledge. This form represents a statement of intention and does not constitute a legally binding agreement to transfer embryos.

2. Confidentiality and Privacy I/we agree to maintain the confidentiality of all information regarding potential embryo donors provided by Her Helping Habit, including but not limited to profiles, photographs, or identifying details. I/we will not use any technology or methods (e.g., reverse image searching) to identify or contact donors without prior written consent from Her Helping Habit. I/we will not share access credentials, including passwords to donor profile databases, with any third party unless expressly approved by Her Helping Habit.

3. Intended Parent Profile Creation I/we consent to the creation of an Intended Parent profile for the purpose of finding a suitable embryo recipient. This profile may include non-identifiable details provided in the application and a photograph of myself/ourselves, which I/we agree to supply.

4. Background Check Authorization I/we consent to a background check by Her Helping Habit or its trusted third-party providers to verify the absence of a criminal record. I/we understand this is a name-based check and not a Vulnerable Sector Check. For non-Canadian participants, we may be required to provide equivalent documentation, such as a "certificate of good conduct" or similar.

5. Dispute Resolution I/we agree that any disputes arising from participation in the program will first be submitted to Her Helping Habit for resolution. Should further dispute resolution be required, I/we agree to refrain from publicly discussing or posting about the matter, including but not limited to online forums, chat sites, or social media groups.

6. Legal and Medical Disclaimer I/we acknowledge that Her Helping Habit is not a medical or legal service provider and does not offer advice or opinions regarding the medical or legal aspects of embryo donation. I/we accept full responsibility for seeking independent legal and medical advice where necessary.

7. No Guarantee I/we understand that participation in this program does not guarantee a successful match with a recipient. Her Helping Habit makes no representations or warranties regarding the suitability, availability, or medical history of any Intended Parents.

8. Release and Indemnity I/we hereby release and discharge Her Helping Habit, its employees, contractors, and representatives from all liability, actions, claims, and demands related to my/our participation in the Embryo Donation Program. I/we agree to indemnify and hold harmless Her Helping Habit from any loss, damage, or expense incurred as a result of participation in this program.

9. Affirmation of Truthfulness I/we affirm that all the information provided in this consent form and the program application is accurate and complete. This consent is provided voluntarily, without coercion 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?