EmailMe Form - Egg Donor - Extended Profile USA

Welcome to Cryos’ Extended Profile Questionaire.

Advice before filling out the form:

• Please fill out as much as possible in English.
• Read the questionnaire thoroughly before you start filling out the form, as most of the questions are obligatory to answer (marked with a red *).
• It is possible to save you answers along the way by using the link at the bottom of the page next to the Submit button. Your answers will be saved for a maximum of 5 days, before it is reset.
• When you click the Save button, please copy and save the link on the following page, as it is a different link than the one given to you by the Cryos staff.
• We advise you to gather all the information you will need before you start. Of particular concern is the section about family information, the handwritten motivation and baby photos in the last part of the form.
• Please leave out any identifying information about yourself in your answers other than your name and ID-number.
• It is important that you give the profile a personal touch. Elaborate and comment on your own answers. Example of a question:

What childhood event left the biggest impression on you? "When I was ten years old, my grandparents took me and my sister camping for a whole week. We picked wild berries, played hide-and-seek in the forest and went swimming in the lake. Nights were spent around the bonfire and while enjoying the berry pies my grandmother had made, my grandfather told stories about the old days and about all the important things in life. This was a great bonding experience and it created a lasting memory of spending time with my grandparents."

We, of course, make sure that your name, ID number and email address is not going to appear in the final profile.

It generally takes 1 - 1.5 hours to complete the form.

Enjoy!

Name *

First Last

ID-number *

Email *

In which Cryos department are you a donor? *

Orlando

Physical Characteristics

Look-alike - List one or more internationally known celebrities you look like *

Build *

Facial Shape *

Round

Oval

Square

Long

Hair *

Fine

Medium

Thick

Hair color(s) as a child *

Color of eyebrows *

Lips *

Narrow

Medium

Full

Shoe size *

Clothing size: *

Do you wear glasses or lenses: *

Glasses

Lenses

No

Education & Occupation

Did you completes high school/GED?

Yes

No

If yes, what did you do immediately after you graduated?

Are you attending or have you finished a trainee program/apprenticeship?

Yes

No

If yes, please state which

Are you or have you been attending university or any other higher education?

Yes

No

If yes, please state what type (technical school, community college, university)

If yes, what was your major/emphasis/focus of study? What other courses did you take? (please be detailed)

How many years of education have you completed?

How many additional years do you plan to spend on education?

If you plan to spend additional years on your education, what type of schooling/degree will you be pursuing?

Please describe your current education and/or job *

Which jobs have you had (please list all)? *

What is/are your overall education/career goal(s)? *

What is your native language? *

Which other languages do you speak? *

Have you carried out any volunteer work? If so, please state which

Do you have any professional certifications/licenses? If yes, please state which

Have you been in the military? *

Yes

No

If yes, please state rank

Personality

Which words describe your personality? (minimum 5 words) *

Describe your strong sides *

Describe your weak sides *

Marital status? *

Single

In a relationship

Married

Which types of sports do you play or have played? *

Which other types of sports are you interested in? *

List any other hobbies you may have or have had *

List which musical instruments you play or have played *

How many hours of sleep do you get on an average night? *

Do you eat healthy? *

I wish

I try

Always

Do you smoke? *

Yes

No

Sometimes

How much alcohol do you drink on average per week? *

Which countries have you visited? *

Describe the best vacation you have had *

Describe the things you like the most about your country *

Who are your idols, heroes and heroines, and why? *

What were your childhood dreams? *

What is/are your goal(s) in life? *

Which value(s) do you rank the highest? *

Which childhood experience made the biggest impression on you? *

What is your favorite...(please state why)

Animal *

Food *

Music *

Car *

Time of year *

(For example summer or Christmas)

Book and/or Author *

Movie and/or Director *

Which experience/moment in your life was your...

Greatest *

Happiest *

Funniest *

Scariest *

Proudest *

Greatest sorrow *

Most dangerous *

If you have something to add regarding your personality or type, please feel free to add it here

Health information

Do you have any allergies? *

Yes

No

If yes, please state which and if medical treatment is required

Do you have any physical abnormalities? *

Yes

No

If yes, please state which

Do you suffer from any illnesses? *

Yes

No

If yes, please state which and if medical treatment is required

Family Information

Help for filling out this section:

• Under ‘Health’ please indicate "Good" for healthy and write shortly about any disease or cause of death.
• If you do not know the exact height and/or weight of family members, indicate such approximately.
• If he/she is no longer alive, indicate age at time of death.
• If he/she has retired, please indicate former occupation.

Paternal Grandfather

Age *

Alive? *

Yes

No

Education(s) *

Occupation(s) *

Race *

(African, American Indian, Asian, Caucasian, Hispanic and/or Middle Eastern)

Ethnicity *

(Ethnicity refers to the ethnic origin of a person's ancestors – where your family comes from. Examples of ethnicities are German, Irish, Venezuelan, etc. Ethnicity should not be confused with race or citizenship)

Height (ft & in) *

Weight (lb) *

Hair color (original) *

Eye color *

Health *

Paternal Grandmother

Age *

Alive? *

Yes

No

Education(s) *

Occupation(s) *

Race *

(African, American Indian, Asian, Caucasian, Hispanic and/or Middle Eastern)

Ethnicity *

(Ethnicity refers to the ethnic origin of a person's ancestors – where your family comes from. Examples of ethnicities are German, Irish, Venezuelan, etc. Ethnicity should not be confused with race or citizenship)

Height (ft & in) *

Weight (lb) *

Hair color (original) *

Eye color *

Health *

Maternal Grandfather

Age *

Alive? *

Yes

No

Education(s) *

Occupation(s) *

Race *

(African, American Indian, Asian, Caucasian, Hispanic and/or Middle Eastern)

Ethnicity *

(Ethnicity refers to the ethnic origin of a person's ancestors – where your family comes from. Examples of ethnicities are German, Irish, Venezuelan, etc. Ethnicity should not be confused with race or citizenship)

Height (ft & in) *

Weight (lb) *

Hair color (original) *

Eye color *

Health *

Maternal Grandmother

Age *

Alive? *

Yes

No

Education(s) *

Occupation(s) *

Race *

(African, American Indian, Asian, Caucasian, Hispanic and/or Middle Eastern)

Ethnicity *

(Ethnicity refers to the ethnic origin of a person's ancestors – where your family comes from. Examples of ethnicities are German, Irish, Venezuelan, etc. Ethnicity should not be confused with race or citizenship)

Height (ft & in) *

Weight (lb) *

Hair color (original) *

Eye color *

Health *

Father

Age *

Alive? *

Yes

No

Education(s) *

Occupation(s) *

Height (ft & in) *

Weight (lb) *

Hair color *

Eye color *

Gender

Full or half sibling

Age

Alive?

Yes

No

Education(s)

Occupation(s)

Height (ft & in)

Weight (lb)

Hair color

Eye color

Health

Do you have any children? *

Yes

No

If yes, please describe each child thoroughly in terms of height, weight, hair and eye color, personality, interests, strong and weak sides, growth and development, and medical information

Attach a file containing a handwritten note about your motivation for becoming a donor (min. 100 words) *

Write as much as possible in English and at least 100 words, but preferably more. Write about your motivation for becoming a donor, your personal message to the child/family and/or other information about yourself.
The motivation must be written by hand in blue or black ink on white A4/Letter sized paper.

The file must be scanned in one of the following formats pdf, jpeg, png or similar. I you do not have the opportunity to scan your motivation and attach it here, you can bring it to your local department and they will make sure that it is scanned and stored with your extended profile.

Attach a recording in which you read your handwritten message out loud
(please see the instructions below)

Attach an audio file in which you read out loud your handwritten message. The voice recording must be loud and clear and without any background noise.

Please do not mention any identifying information, such as your name.

Attach the voice recording as an audio file. You can make the recording with a mobile phone, iPod, computer, dictaphone, etc. If it is not possible for you to make the recording yourself, we can help you the next time you visit Cryos.

Attach Baby and Adult Photos *

Attach ONLY images in digital form. Please do not take pictures of pictures - AKA, do not take a photo with a mobile phone of a picture on the wall or in an album.

We need the quality to be as good as possible, preferably portrait photos.

We will make sure to remove any family members/friends or other identifying items from photos.

Please refrain from sending only close-up selfie photos. If possible, please send at least one photo that shows your face and body.

If you do not have the opportunity to scan the images, attach an arbitrary image, and bring the photos to your local Cryos office and we will help you scan them.

Attach additional Baby/Adult Photo

Attach audio file

The audio file can also be recorded at your department.

Date filled out *

DD / MM / YYYY

Welcome to Cryos’ Extended Profile Questionaire.

Physical Characteristics

Education & Occupation

Personality

What is your favorite...(please state why)

Which experience/moment in your life was your...

Health information

Family Information

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Father

Mother

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Sibling 5

Sibling 6

Thank you for filling out the form!