Donor Application for San Diego, CA

Note: All answers are verifiable with medical testing required during the process.

Note: All information is confidential and used only for determining
eligibility and contacting the donor.

Personal Information & History
First Name:
Last Name:
Have you applied previously as a sperm donor with our facility?  Yes   No
Email Address:
Confirm Email Address:
Phone Number:
Date of Birth:  (mm/dd/yyyy)
Country of Birth:
Weight (lbs):
Hair Color:
Eye Color:
Mother's Ethnic Origin:
Father's Ethnic Origin:
Your Parentage:  Natural child of parents   Adopted
Occupation & Education
Please enter student if you are one
Are you currently attending a college or university? YesNo
What is the name of the college you are attending or graduated from?
What is your current level of education?
Medical History
Have you taken any medications, drugs or pills in the last several months?  No   Yes
If "Yes" please describe.
This includes any recreational drugs or medication.

Your sexual orientation:  Heterosexual
How many sexual partners have you had in total?
How many sexual partners have you had in the past 6 months?
How many sexual partners do you currently have?
Have you ever had sex with anyone in exchange for drugs or money, or has anyone you have had sex with done the same?  Yes   No
Have you ever had relations with someone suspected of HIV or viral hepatitis?  Yes   No
Have you had any illnesses?  Yes   No
If "Yes" please describe:
Are there any known birth defects or genetic conditions in your family?  Yes   No
If "Yes" please describe:
Have you or any of your family members been diagnosed with alcoholism?  Yes   No
If "Yes" please list:
Do two or more members of your family have the same medical condition?  Yes   No
If "Yes" please specify who and what condition:
Have you traveled outside the U.S. in the last 3 years?  Yes   No
If "Yes" please describe:
How did you hear about our program? Please Specify
(where applicable)
Would you be interested in participating in an identity release sperm donor program that would allow offspring to access your contact information when they reach the age of 18?  Yes   No
Would you be interested in participating in an altruistic (minimum pay or unpaid) portion of the donor program?  Yes   No
OPTIONAL: We would like to be able to attract potential donors via the internet at sites popular with you and your peers. Do you have a favorite website(s) that you visit frequently?


Thank you for your interest and time.
We will contact you by email on the status of your application.