A trusted resource for women planning alternative families

Donor Initial Application

Please fill out the following form to be considered for donation. All form fields are required. Note: If emailing this form, we cannot guarantee the security of your information. If web security is a concern to you, please print our PDF form and fax it to us.

Part I: Personal Information

Please indicate your personal and contact information:

First Name:
Last Name:
Mobile Phone No.:
Home Phone No.:
Work Phone No.:
Email Address:
(PRS will contact you via this email address)
Best Time To Contact You:
Address (No P.O. Boxes):
Apt. No. (if applicable):
Zip Code:
Ethnic Background (Mother):
Ethnic Background (Father):
Height (Ft/In):
Weight (Lbs):
Date of Birth (Month/Year):
Are you currently enrolled in or applying to school? Yes   No
Do you have any special training or certifications? (max 50 char.)
(max 50 char.)
Employment Status:
Are you a U.S. citizen? Yes   No
Are you currently in the military, active duty or reserve? Yes   No
To which office are you applying?

Part II: Medical History

Do you or anyone in your family have a history of:

Heart Disease: Yes   No
Diabetes: Yes   No
Birth Defects: Yes   No
Genetic Conditions: Yes   No
Cancer: Yes   No
Mental Illness: Yes   No
Alcoholism/Substance Abuse: Yes   No
Do you drink alcohol? Yes   No
Do you smoke cigarettes? Yes   No
Do you have access to your biological family's medical history? Yes   No
Are you able to make a one-year commitment? (donating on average once weekly?) Yes   No
Have you had oral or anal sex with another male in the past 5 years? Yes   No
How many sexual partners have you had in the last
6 months:   
1 year:
Have you ever been a donor for a sperm bank? Yes   No
How long have you lived in the area? yrs   mo
How did you hear about us?

(Please only press submit once.)

Download Adobe Acrobat Reader Here! NOTE: To download our Acrobat (.PDF) files, you'll need Adobe Acrobat Reader installed on your system. If you don't have it installed, please do so (for free!) by clicking on the logo at right.