Apply to Become a Sperm Donor

Please fill out the application below for our sperm donor program.
If you have any questions please contact info@spermbankcalifornia.com.

 
Donor Application
 
Last Name: First Name: Middle Name:
   
 
Daytime Phone: Evening Phone: Mobile Phone:
   
May we leave a discreet message?
No Yes
 
Address:
City: State: Zip:
   
 
 
Please provide us a valid email address. We will contact you via email to tell you the status of your application. Your email address will also be your username.
 
Email: Re-type Email:
 
Check here if you do not have an email account.
  "none@SpermBankCalifornia.com" will be your username.
 
Password: Re-type Password:
 
Passwords must be 4-8 characters.
 
 
How did you find Fertility Center of California?
 
Please tell us about yourself:
 
Date of Birth:
 
Height: Weight:
Ft.  In. Pounds
Body Frame: Skin Complexion:
Hair Color: Hair Type:
Eye Color: Blood Type:
 
Religion:
Place of Birth:
  (State/Country)
 
Race:
Please check ALL that apply.
You may check more than one.
African-American
Alaskan Native
American-Indian
Asian
Caucasian
Latino
Native Hawaiian-Other Pacific Islander
Other: 
 
Mother's Ethnic Origin:
Please check ALL that apply.
You may check more than one.
African American
American Indian
Brazilian
Czech
Dutch
English
French
German
Indian
Irish
Italian
Japanese
Jewish
Mexican
Norwegian
Polish
Portuguese
Russian
Scottish
Slovakian
Spanish
Swedish
Welsh
Yugoslavian
Other: 
 
Father's Ethnic Origin:
Please check ALL that apply.
You may check more than one.
African American
American Indian
Brazilian
Czech
Dutch
English
French
German
Indian
Irish
Italian
Japanese
Jewish
Mexican
Norwegian
Polish
Portuguese
Russian
Scottish
Slovakian
Spanish
Swedish
Welsh
Yugoslavian
Other: 
 
Marital Status:
Are you adopted?
   
Have you ever
caused a pregnancy?
If yes, how many, when, and outcome of pregnancy?
   
Indicate Date/Days
since last ejaculation:
   
Number of Siblings:
   
Present Occupation:
College Degree:
If Student, School Name:
Student Year:
College Major:
 
Have You?
a) ever used non-therapeutic injected drugs?
b) received clotting factors such as Factor VIII or Factor IX which are not heat treated or otherwise viral inactivated?
c) engaged in prostitution?
d) been the sexual partner of anyone who would answer Yes to a), b) and/or c)?
e) been the heterosexual partner of any HIV positive person?
f) acquired a tattoo in the past year?
g) ever been infected with Hepatitis B or C?
h) been the sexual partner of a person known or suspected to have Hepatitis B or C?
 
If invited for further screening, I agree to undergo all required testing and evaluation. If accepted into the donor program, I will donate specimens for a minimum of 12 months starting from my membership date. To prevent transmitting diseases that may adversely affect the quality of my sperm or impair the recipients and/or any potential offspring’s health, I will volunteer truthful information regarding my sexual history and health status, past, present and in the future. I hereby agree to be tested for all communicable diseases including but not limited to HIV/HTLV. I understand that sperm banks are required by law to release my name to the State Depart. of Health if I test positive for HIV, HTLV, Hepatitis and Syphilis and that I may be required to undergo counseling to prevent the spread of these diseases to other people. FCC will be financially responsible for all screening and tests. If I test positive for any test, FCC will drop me from the program and I am not responsible for any fees. However, if I test negative but choose to drop out (because I change my mind), I am responsible to pay for those tests already performed.
 
I agree to these terms and conditions I Agree
 
 
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