Donor application
1
2
3
4
5
6
7
8
9
Section 1
Personal information
No
Yes (please specify)
Section 2
Personal background
Black
Caucasian
Indian
Coloured
Mixed race
Please select if you will provide this information later
Married
Single
Domestic Partnership
Divorced
No
Yes (please specify)
No
Yes
No
Yes
Section 3
Physical attributes
Blonde
Light brown
Dark brown
Red
Black
Straight
Wavy
Curly
Ethnic
Brown
Green
Blue
Grey
Porcelain
Ivory
Warm ivory
Sand
Warm beige
Golden
Chestnut
Cocoa
Espresso
A
B
AB
O
Do not know
Left
Right
Ambidextrous
Legally blind
Poor (have to wear glasses/contact lenses)
Fair (occasionally have to wear glasses/contact lenses)
Good
Excellent (20:20)
Legally deaf
Poor
Fair
Good
Excellent
Please select if you will provide this information later
Square
Triangle
Inverse triangle
Oval
Hour glass
Heart
Round
Oval
Diamond
Hooked
Thin
Aquiline
Greek
Button
Upturned
Pointy
Small
Natural
Pointy
Thin
Cupid's bow
Uni-lip
Beesting
Wide
Glamour
Almond
Hooded
Deep-set
Round
Sleepy
Downturned
Section 4
Personal medical history
No
Yes - please give company/clinic details and reason
No
Yes - please give details on the surgery type and reason
No
Yes - please give details
No
Yes - please give details
No
Yes - how much per day?
No
Yes - how often per day/week?
No
Yes - please give details
Poor
Fair
Good
Excellent
No
Yes - please give details
No
Yes - which date did you get the most recent tattoo done?
No
Yes - state which date and/or year
No
Yes - when last did you donate?
No
Yes
No
Yes
No
Yes
No
Yes - please give details (kind of STD, when was it diagnosed, and have you received treatment for it)
No
Yes - please give details
No
Yes - please give details
No
Yes
Section 5
Family medical history
Please select if you will provide this information later
No
Yes - please give more detail (family member, condition/disease and severity eg. Grandmother had breast cancer and died of cancer in 2016)
Condition
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Thalassaemia
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Tay Sachs
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Cystic Fibrosis
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Muscular dystrophy
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Porphyria
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Sickle cell anaemia
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Stroke
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Heart attack
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
High Blood Pressure
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Hereditary cholesterol
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
High Cholesterol level
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Leukaemia
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Asthma
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Lung cancer
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Ulcer
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Hepatitis
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Crohn's disease
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Diabetes I
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Diabetes II
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Thyroid disease
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Lupus
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Kidney Disease
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Migraines
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Senility before the age of 50
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Epilepsy/Seizures
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Parkinson's
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Depression
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Bi-Polar
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Schizophrenia
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Osteoporosis
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Arthritis
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Deafness
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Blindness
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Eczema
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Acne
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Breast Cancer
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Ovarian cancer
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Prostate cancer
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Colon cancer
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Skin cancer
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Thyroid cancer
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Cervical cancer
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Uterine cancer
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Other cancer
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Alcoholism
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Drug abuse/ addiction
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Polycystic ovaries
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
Endometriosis
You
Father
Mother
Sibling
Paternal GF
Paternal GM
Maternal GF
Maternal GM
No
Yes - please give details
Section 6
Education and employment
No
Yes - please name the institution and field of study
No
Yes - please give details (eg. waiter over weekends at Dros)
No
Yes - please give details (eg. Creative Director at Think Big Creative Agency)
Section 7
Hobbies and interests
No
Yes - please specify what kind of exercise, and how often per week (eg. 30min run four times a week)
No
Yes - please specify what kind
No
Yes - please specify what kind
No
Yes - please specify what kind
No
Yes - please specify what kind
Section 8
Personality traits
No
Yes - please specify
Introvert
Adventurous
Impulsive
Confident
Relaxed
Well-behaved
Optimist
Competitive
Arrogant
Imaginative
Extrovert
Reluctant
Precise
Pessimist
Bossy
Dependable
Picky
Reliable
Ambitious
Opinionated
Inquisitive
Observant
Accurate
Attentive
Humble
Dreamer
Persistent
Perfectionistic
Indecisive
Forgetful
Helpful
Assertive
Problem-solver
Trusting
Encouraging
Easily distracted
Hard-working
Compassionate
Meticulous
Polite
Honest
Patient
Impatient
Romantic
Adaptable
Courageous
Curious
Well-mannered
Particular
Empathetic
Loyal
Trustworthy
Section 9
Declaration of truth and accuracy
No
Yes
I understand that my application will be denied if any information provided is false or innacurate
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Submit Application
Donor application submitted
Thank you very much for you time and honesty in applying to be a sperm donor at Wijnland.
Your application has successfully been submitted to our donor bank. You will receive a confirmation email shortly, acknowledging receipt of your application.

Applications take 5 - 10 working days to be processed by our lab. You will be contacted with the results of your application via telephone.

If successful, you will be asked to come in to the clinic to discuss the next steps going forward.
If you have any questions, please feel free to contact us directly on our contact page.