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Apply Today: I Want to be a Surrogate Mother!

The first step to becoming a surrogate mother starts here.

Thank you for your interest in becoming a surrogate mother. If you would like more information about our gestational surrogate program in general, please call 949 861-4100 or complete the form below. A West Coast Surrogacy representative will reply to your request promptly!

First Name:*
Last Name:*
Address:*
City:*
State:*
Zip:*
Home phone: *
Mobile phone: 
Email Address:*
Date of Birth:*
Number of Pregnancies:
Number of Cesarean Sections:
Number of Children:
Ages of Children:
Height:
Weight:
Marital Status:

Name of health insurance carrier:
Complications during pregnancy?
Do you receive state or federal financial aid?
Are the following statements completely true? *
Yes   No
  • I am a U.S. citizen (or permanent resident), between 22 - 40 years old.
  • I am in excellent health, with a healthy BMI, don't smoke and don't use any drugs.
  • I have given birth at least once to a child I am raising, and my pregnancies have been full-term and free of complications.
  • I am willing to undergo a psychological consultation and background check.
    (Note that your husband/partner will also require screening.)
If no, please explain:
Why would you like to become a surrogate?
Comments:
Candidate Requirements:
  • Between 22 - 40 years old
  • Given birth at least once to a child you are raising
  • All births 36+ wks; Complication Free
  • Be a U.S. citizen (or have permanent U.S residency)
  • Non-smoker / Drug Free
  • Have a Healthy BMI (BMI calculator)
  • No State or Federal financial aid
  • Be willing to administer self-injections
  • Be willing to undergo a background check (husband/partner included)
  • Be willing to undergo a psychological consultation