It's easy to apply

Our agency is graced with so many caring donors, we hope you will be one of them. To do so, simply fill out the 4-page application below. Each page should take only 5 minutes to complete. Please note that the more complete your application is, the better your chances are to be chosen as a donor.

Thank you for considering Graceful Conception.

Application

Name:	Location/Address:
Email Address:	Phone:	Home	Cell
Best way to contact: Email Phone

Physical Description

Race:

Ethnicity:

Date of Birth:

Height:

Weight:

Eye Color:

Natural Hair Color:

Hair Texture:

Hair Type:

Complexion:

Physical Build:

Teeth:

Braces? (indicate date)

Glasses/
Contacts?

Hearing:

General Information

Citizenship:	US Other:
Blood Type:		RH Factor: Positive Negative
Marital Status:		Sexual Orientation:
Religion Born Into:		Current Religion:
Do you smoke?	Yes No Socially
Do you drink alcohol?	Yes No
If yes, how often?	Daily 2-4 times a week Weekends only Less
Do you currently use any illegal drugs?		Yes No
Have you used any illegal drugs within the past five years?		Yes No
If so, please indicate which ones and frequency:
Would you consent to a drug test?		Yes No
Do you have tattoos or body piercings?		Yes No
If yes, please list location(s) and date:
Have you ever been arrested and/or incarcerated for more than 72 hours?		Yes No
Would you consent to a criminal background check?		Yes No
Are you in a monogamous relationship?		Yes No
If yes, would your partner consent to infectious disease and/or drug screening?		Yes No
If no, how many sexual partners have you had within the past 6 months?
Were you adopted?		Yes No
Do you have any allergies?		Yes No
Do any of your family members have allergies?		Yes No

FDA Risk Information

Have you ever injected anything for non-medical reasons?	Yes No
Have you had more than 10 sexual partners in your lifetime?	Yes No
Have you ever had sex with a man who engaged in sexual activities with other men?	Yes No
Have you engaged in prostitution, or had intercourse with someone who engaged in prostitution since 1977?	Yes No
Have you had intercourse with someone who tested positive for HIV within the past five years?	Yes No
Have you received a blood transfusion within the past 12 months?	Yes No
Have you ever been denied as a blood donor?	Yes No
If yes, please list reason(s):
Have you recently been exposed to rabies, SARS, malaria, radiation, or toxic chemicals?	Yes No

Education

Highest level of education attained:		High School College Degree
Name of high school:
AP/Accelerated courses:
Extracurricular activities:
Name of college:			College GPA:
College major:
Extracurricular activities:
Graduate/other course work:
Have you taken an IQ test?	Yes No If yes, score and date taken:
PSAT score:		SAT score:		ACT score:
Mother's highest level of education:
Mother's profession:
Father's highest level of education:
Father's profession:
Any other pertinent educational information:
Any siblings?	Male - how many		Female - how many

Talents and Abilities

What was your favorite subject in high school?
What subjects or courses did you excel in?
What languages, other than English, do you speak?
Please indicate whether or not you are fluent:
Do you play a musical instrument?	Yes No
If yes, please list type and years played:
Do you have vocal abilities?	Yes No
If yes, please describe:
Do you have any writing or communication abilities?	Yes No
If yes, please describe:
Do you currently plan any team sports?	Yes No
If yes, please list type and years played:
What do you do to keep fit?
Do you have any other talents or abilities you would like potential recipients to know about?