Donor Application Form DONOR APPLICATION FORM Your First Name :* Your Surname :* Your Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Email Address :* Your Contact Number :* Your Province*GautengLimpopoMpumalangaNorth West ProvinceFree StateKwazulu NatalNorthern CapeEastern CapeWestern CapeOtherOtherYour Ethnic race*BlackWhiteColouredIndianChineseOtherPlease provide "Other" race group.Even though you will be measured for weight in our office, please provide us your weight.* Even though you will be measured for height in our office, please provide us your height.* What is your highest level of education?*What is your highest level of education?MatricCertificateDiplomaHigher DiplomaDegreeHonors DegreeMastersDoctorateHow many times have you applied to be an Sperm donor?* How many times have you donated your sperm?* Will you be available to donate your sperm in the next 4 to 6 months?*Will you be available to donate your sperm in the next 4 to 6 months?YesNoDo you smoke?*Do you smoke?YesNoHow many cigarettes (or any nicotine product) do you smoke per day? Are you currently taking any medications prescribed or over the counter?*Are you currently taking any medications prescribed or over the counter?YesNoIf Yes, Which medications?Even though you will be tested for Drug use in our offices, have you partaken in the use of any of the below listed Drugs within the last 3 months?* Opiates Amphetamine Methamphetamine Cannabis Cocaine None Are you currently taking any diet pills or herbal medications?*Are you currently taking any diet pills or herbal medications?YesNoIf Yes, Which medications?Have you been diagnosed for any of the following within the last year?* HIV Hepatitis B Hepatitis C Other STD's None Have you been diagnosed/or do you currently have any serious medical conditions?* Yes No Have your sexual partners in the last 5 years been?* Male Female Both Are you adopted?*Are you adopted?YesNoHow did you FIRST learn about the opportunity to donate your sperm at VCSA?*How did you FIRST learn about the opportunity to donate your sperm at VCSA?FacebookOur WebsiteFriend / FamilyTwitterYouTubeRadioPrint AdvertThe information that I have provided is correct. I agree to participate in the VCSA Anonymous Confidential Sperm Donation Program. I will make myself available to attend all scheduled appointments at the clinic during working days and hours.* I consent Please enter your initials here:* What is your email address for communication with you regarding your pre-screen application?* Please verify your email address* CAPTCHA
