I Want to Be a Surrogate Mother

Surrogate Mother Qualifications

Be a resident of California
Between the Ages of 21 and 40
Height and Weight Ratio Appropriate (max 200 lbs.)
Have previously given birth
Excellent Health
Non-smoker

Thank you for your interest in being a Surrogate Mother. For more information about being a Surrogate Mother, please complete the following form. If you encounter errors with this form please email us at: form@buildingfamiliesinc.com

*Required Fields

Full Name*:

Address Line 1*:

Address Line 2:

City*:

State*:

Zip*:

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Phone*:

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Email*:

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Confirm Email*:

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Best Days and Time to Contact*:

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Married?*

Have you given birth to one or more children?*

Date of Birth (Month)*:

Date of Birth (Day)*:

Date of Birth (Year)*:

Age*:

Weight (in lbs.)*:

Height*:

Birth Control*:

Birth Control Type* (If you're not taking birth control please select "None"):

Please Explain your Birth Control:

Smoker*:

Are You on Public Assistance?*

What type of Public Assistance - Please Explain?

Please List All Medications you are currently taking*:

If you are not currently taking any medications, please type "N/A" or "Not currently taking any medications".

Your Occupation*:

Do you have Health Insurance?*

Name of Health Insurance?

Do you have any Questions or Comments?

How did you hear about Building Families, Inc.?*

We would appreciate you letting us know how you heard of Building Families, Inc. If you don't know please select "I don't know" at the bottom of the list. Thank You!

If a person or company referred you to Building Families, let us know so we know who to thank.