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: Anytime 9AM - 11AM 12PM - 2PM 3PM - 5PM Address (No P.O. Boxes): Apt. No. (if applicable): City: State: California Only Zip Code: Ethnic Background (Mother): Ethnic Background (Father): Height (Ft/In): Under 5' 5" 5' 5" 5' 6" 5' 7" 5' 8" 5' 9" 5' 10" 5' 11" 6' 0" 6' 1" 6' 2" 6' 3" 6' 4" 6' 5" 6' 6" 6' 7" Over 6' 7" Weight (Lbs): Date of Birth (Month/Year): 1 2 3 4 5 6 7 8 9 10 11 12 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 >1993 Are you currently enrolled in or applying to school? Yes   No If so, what level? Please select Associate Bachelors Masters Doctorate Level of Education Completed: Please select High School College Postgraduate Do you have any special training or certifications? (max 50 char.) Profession: (max 50 char.) Employment Status: Student Full Time Part Time Unemployed Are you a U.S. citizen? Yes   No If no, what is your status? Please select Student Visa Green Card Work Permit Other Are you currently in the military, active duty or reserve? Yes   No To which office are you applying? San Francisco Pasadena 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 (if so, how many drinks/week) Do you smoke cigarettes? Yes   No (if so, how many cigarettes/day?) 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:    0'; 1 2 3 4 5 1 year: 0'; 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 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? Bing Craig's List Daily Trojan Friend Golden Gate Xpress Newspaper Golden Gate Xpress Website Google Other Search Engine Poly Post PRS Web site The Guardsman Yahoo (Please only press submit once.)

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