Please complete the application below and click submit. Your application will be reviewed and, upon acceptance, added to the list within 24 hours of receipt. The information given below qualifies individuals for participation in the mailing list. This information will never be released or sold to any individual or company. It is needed to ensure that only individuals who have an interest in being surrogate mothers are admitted to this online support group. Thank you. BEFORE YOU SUBMIT Please recheck your e-mail address to ensure it is accurate. If we do not receive the correct e-mail address, it will be impossible for us to contact you to let you know that the server cannot reach you. We do NOT reject applications without contacting the applicant to discuss why they are being rejected. So if you do not hear from Fortility within 48 hours, you can assume there is some problem with your e-mail address. Either re-submit or contact the moderators directly.

Name

First  Last

Email

(confirm email)

Create the password that you want to use to access the list Archives and Account Management website.

Your Location:

City    State/Province   Country

Age

20-25 26-30 31-35 36-40 41-45 46-50 50+

Have you been a surrogate before?

Yes No

If yes, how many times?

If yes, please discuss.

Have you had any pregnancies?

Yes No

If yes, how many went to term?

How many children do you have, if any?

What are your children's ages?

My interest in surrogacy in best described by (Please respond to the following statements...)

I have been a surrogate in the past:

Yes No

I plan to be a surrogate in the near future:

Yes No

I am currently pregnant with a child(ren) for an intended family:

Yes No

I am just exploring the idea of being a surrogate and would like to communicate with other surrogates :

Yes No

Please let us know how the On-Line Support Group can help you:

You may choose how you would like to receive the list messages.

Individual messages as they are generated Digest - One email per 24hr period containing all of the messages from that day

How did you hear about us?

I agree to abide by the Rules of Conduct  to retain my privilege to participate in this online support group. I understand that if I violate any of these rules, I may be unsubscribed, without warning, to protect the best interest of the group.