First Name                                                     

Last Name

Mailing Address

City                                                                 State                                                              Zip Code  
                                                                          
Home Phone                                                   Cell Phone                                                    Preferred Contact Method

E-mail                                                          Important Forms are sent via e-mail, so provide an e-mail you check daily.

Ethnicity

Mother's Ethnicity (Country of Origin)

Father's Ethnicity  (Country of Origin)

Race ( White, Black, Hispanic, Asian, Native American)

Religion

Are You Willing To Travel?

Date of Birth

Height

Weight

Eye Color

Hair (Natural)


Educational Background


Highest Educational Level:
 
SAT:                                                   

ACT:  
        
College GPA:                              

High School GPA:

Major/Degree

Educational Goals:


                                                                     Family History

         
        
                                                    Age                            Height                                  Hair Color                                    Eye Color 
 


Father:      
                


         
Mother:  


          
Paternal Grandfather: 


   
Paternal Grandmother:  

          

Maternal Grandfather:  


          
Maternal Grandmother:  
          
      
                                                Age                               Height                                    Hair Color                                   Eye Color

Sibling 1   

Sibling 2

Sibling 3 

  
                                                                    Your Children

                      Age                                                               Eye Color                                                                 Hair Color
     
1.

2.

3.





Your Personality




Describe Your Personality





Describe Yourself As A Child






Hobbies/Talents:





 
What kind of food do you like?






What kind of music do you like?







What is your favorite song?







What is your favorite animal and why?







If you could go anywhere in the world, where would you go?







What do you consider is your greatest accomplishment?



 


Why do you want to be a donor?







Is there anything you would want to say to the intended parents?

 




 
Do you speak other languages? (Please list)
 






Do you or have you ever played any sports and when?
 


Medical History


Blood type : 


 
General Health Condition : 







Do you have any past or current medical problems? Please explain. 







 

 
 





 


. 




 
 


                                                            
Reproductive History
                                    
    
Number of Children:                                Number of Males                                 Number of Females


Number of Pregnancies


Number of Miscarriages


Number of Abortions
                                                   

Are Your Periods Normal?


Have you ever undergone infertility treatments?
     

Has anyone in your family had multiple births (i.e. twins, triplets)?                                     Please indicate relationship

 
Are You A Previous Donor?                                           Did a pregnancy occur? 

                                 
What method of birth control are you currently using, if any?





 



Personal Information


Occupation:


Previous Occupation


Life Goals:


Marital Status:                                            You and your sexual partner may be required to submit to a blood test to rule out                                                                                          communicable diseases before you will be allowed to start the medical                                                                                                          processes of the egg donation procedures
 

Have you ever been arrested? 


If yes, what was the charge? 


Do you smoke?                                    (Please note: that if you live with a smoker who smokes inside, you are considered a
                                                            smoker as well, due to the risks of second-hand smoke.)


Do you drink alcohol? If so, how many drinks per week?


Have you ever had surgery?                                                If so what kind and when?


 
Something interesting about yourself you want us to know.


If married, how does your husband feel about your donation?
(Your spouse will be required to sign all contracts)

 
Who is the most important person in your life, and why?


Would you be willing to meet the intended parents?


Do you want to know the results of your donation?


































































I agree that I represent that all written representations and information provided and/or to be provided to HTHD, and any professional, psychologist, physician, physician's assistant, nurse, attorney, or designee of HTHD , are true, correct and complete.


I agree to allow HTHD, to use my photos and likeness and non-identifying information from my profile to show to prospective couples, individuals and for use on the Internet database for matching purposes only. If I choose not to display my photos on the Internet database, I may request as such in writing.


Print Your Name:




Your Other Comments (if any):








































































































































































































































































































































































































Please list the family member ( including yourself) where it applies below.



Alzheimer's Syndrome                                                                       Miscarriages
 
                                                                                               
Down's Syndrome                                                                                         Gaucher's Disease


Cancer                                                                                                          Kidney Disorders


Lung disorders                       Asthma


Multiple Sclerosis                                                                                         Arthritis


Cystic Fibrosis                                                                                    Allergies

Muscular Dystrophy               

     Stillbirths
Huntington's Disease

  ADD (Attention Deficit Disorder
Diabetes


Depression/Suicide


Thyroid Conditions


Tay Sachs


Sickle Cell Anemia


Blindness/Deafness


Drug/Alcohol addiction      


Schizophrenia


Eating disorders


Dwarfism


Epilepsy/Seizures


Cleft lip or palate


Club foot


Spinal Bifida


Heart disorders                                                                            


Heart Disease               



                                                                     




Ovum and embryo donations are among the most precious gifts possible. In order to safeguard those who donate and receive these gifts, careful screening and testing of the donors is required. Your complete honesty and accuracy are essential and because very sensitive information will be collected, all the information you provide is considered confidential.

Please answer each question with Yes...No...or Don't Know

Have you injected drugs for a non-medical reason in the last 5 years?


Have you had sex for drugs or money in the past 5 years?


In the past 12 months, have you had sex with a person known or suspected to have HIV, or active hepatitis B or C?



In the past 12 months, have you had tattooing, ear or body piercing in which shared instruments were used?


In the past 4 weeks have you had any shots or vaccinations?


Have you been diagnosed with West Nile Virus?


Have any of your blood relatives ever had Creutzfeldt-Jakob disease?


In the past 12 months, have you had a positive syphilis test?


In the past 12 months, have you had or been treated for syphilis or gonorrhea?





Did you spend a total time of 6 months or more associated with a military base in any of the following countries: Belgium, The Netherlands, Germany, Spain,Portugal, Turkey, Italy or Greece?





Since 1980, have you ever lived in or traveled to Europe?
(Includes England, Ireland, Scotland, Wales, the Isle of Man, the Channel
Islands, Gibraltar, or the Falkland Islands)



Since 1980 have you spent time that adds up to 5 years or more in Europe
(including time spent in the UK between 1980 and 1996)?


Have you been in a place affected by SARS or with an affected person within the past 14 days?



Were you born, or have you lived in or traveled to any African country since 1977?



Please Remember to email your photos to:
photos@hthdonations.com
Applications cannot be processed without photos
Please do not complete this on-line application unless you are serious about becoming a potential egg donor and serious about completing the process.  
Being An Egg Donor is a very rewarding process, however it requires a very serious, mature and committed individual.
You will also need to email at least one current photo of yourself after submitting the application.        Applications without a photo cannot be considered.
Donor Application
Agree To Terms
Agree To Terms