Sperm Donor Application

Name:		Postal Code/Zip:
Email:		Telephone:
Address:		Date of Birth:
City:		Where did you hear about us?	Yellow Pages Search Engine (e.g. Google)    Other Websites Eye Magazine Now Magazine Metro Other

In order for us to process your application we need the following confidential information:
Are you or either of your parents adopted?	Yes No
Do you have access to information about your parents and grandparents regarding eye and hair colour, height and ethnic background?	Yes No
Do you have access to health information about your parents and grandparents including their current health status or, if deceased, the age and cause of death?	Yes No
Do you or anyone in your family have any genetic/inherited or major medical disorder?For example: diabetes, heart disease stroke, mental illness or depression, cancer.	Yes No (If YES, please provide details)
Are you currently taking any medication?	Yes No (If YES, please provide details)
Do you use any illegal drugs?	Yes No (If YES, please provide details)
Have you ever donated blood or applied to be a blood donor?	Yes No (If YES, please provide details)
Have you ever been convicted of any criminal offence?	Yes No
Have you ever been imprisoned?	Yes No
Are you willing to come in and donate semen on a regular basis, i.e once a week, after a minimum of a three day abstinence from sexual activity/ejaculation?	Yes No
How long would you be willing to participate in our program?
Are you currently married or in a long-term committed relationship?	Yes No
Have you ever had sex with another man?	Yes No
Has a woman ever become pregnant by you?	Yes No
If so, how many children do have?	Males    Females
Do you have an Ontario Health Card?	Yes No
What is your ethnicity?
What is your occupation?
Are there any special instructions regarding how and when we can contact you? (e.g. Time, Phone Number, Mailing Address)
Comments:

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