Apply - Roots

Let's Get To Know You

Just a few quick details to get started. After this, you'll be able to talk or text with Nora, Roots's screening assistant to get your questions answered and see if surrogacy could be a fit for you.

Personal Information

First Name*

Last Name*

Email Address*

Phone Number*

Enter the phone number with area code.

Date of Birth*

Current State of Residence*

Citizenship Status*

Physical Information

Height (inches)*

Feet

Inches

Weight (lbs)*

Family Information

Have you carried and raised at least one of your own children?*

How many times have you given birth?*

Background Information

Have you ever been convicted of a felony?*

Have you ever had any weightloss surgery?*

Do you have a car and a valid driver's license?*

Do you currently smoke or vape?*

Have you had an eating disorder in the last 5 years?*

Do you have a history of suicidal thoughts and/or attempts?*

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