INFORMED CONSENT-SPERM DONATION
This Informed Consent has been prepared to help inform you as a potential donor (“You,” “Your,” or “Donor”) about the sperm donation process at Premier Sperm Donors LLC (“Premier,” “We,” “Our,” and “Us.”). The purpose of this Informed Consent is to provide you information so that you can make an informed decision whether or not to donate after knowing the potential risks and benefits involved. It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page, and sign the consent for the donor process described below.
Sperm donation (“Donation”) is a voluntary process. Some Donors wish to donate sperm samples (“Sample(s)”) for third party recipients to use in assisted reproduction (“Recipients”).
Premier coordinates the collection and processing of Samples. If You have questions about the language in this Informed Consent or the accompanying Donor Agreement, please ask Us. We encourage You to consult independent counsel for legal advice.
Risks and Disclosures
1. Background Check: To ensure the accuracy of donor background representations, ensure the integrity of Premier data, and comply with regulatory requirements, we request certain background information, including without limitation family, medical, education, and work history. You agree and certify by signing below that all information provided to Premier about you is true, accurate, and complete to the best of your knowledge. You acknowledge and agree that Premier is authorized to conduct background checks that may include all representations you make, including but not limited to confirming and verifying the absence of any criminal convictions or pending charges, educational history (e.g. degrees earned), and sex offender status. You have the right to request a copy of the background check report upon completion. By initialing here and signing below, you (a) authorize our background check, investigation, collection, use, and disclosure of information obtained from a background check for the purpose of evaluating your eligibility as a Donor, the result of which will be disclosed to authorized Premier personnel involved in donor screening; and (b) acknowledge that Premier reserves the right to decide who is eligible and qualified to become a donor, is not required to explain its decision, and You waive your rights to contest eligibility determinations.
INITIALS: ______________
2. Medical and Genetic Testing: To comply with the law, Premier conducts certain medical, genetic, and infectious disease testing on donors to ensure the quality and safety of donated Samples for future use. The FDA requests testing (both prior to donation and six (6) months after donation) for the following infectious diseases: HIV, Hepatitis B, Hepatitis C, Human T-lymphotropic virus, Cytomegalovirus, Syphilis, Gonorrhea and Chlamydia, and Premier reserves the right to modify and expand testing and screening beyond FDA or other requirements, whether as recommended by public health authorities or otherwise as deemed appropriate to address emerging health concerns. You authorize us to perform all tests required by law or as we otherwise determine to be appropriate. You consent to disclose all known medical conditions accurately and completely, to provide a blood and urine sample, undergo physical examination, and provide a Sample for analysis (including without limitation volume, sperm count, motility and shape). You consent to all necessary testing, including follow up testing after donation. You acknowledge that Premier is not serving as your care provider and will provide you with reports at your request so that you can follow up with your doctor independent of Premier at your sole expense.
INITIALS: ______________
3. Confidentiality:
• Disclosure of Identity: California law provides Donor with the right to choose whether or not to disclose Donor’s identity upon request by an individual 18 or older conceived via Donation. You acknowledge that, although California law only provides for disclosure with mutual consent, Premier has elected to collect Samples exclusively from those Donors who consent to such disclosure. You acknowledge that You understand and are agreeing to disclose Your identity and to execute a separate declaration that states Your agreement to disclose Your identity to an individual conceived by assisted reproduction with Your Sample, upon request, when the person reaches 18 years old.
• Disclosure of Nonidentifying Information: In compliance with California law, You acknowledge that We are required to disclose Your nonidentifying medical information to the parent or guardian of a minor conceived via Your Sample, upon request or, upon 18, to the individual conceived by assisted reproduction with Your Sample, upon request.
• Risk of Genealogical Discovery: Although We will not voluntarily disclose your identity except as noted above, we cannot guarantee protection of your personal identity from outside data sources given recent advances in digital and genealogical technology.
• You agree not to disclose any confidential information related to the Sample donation process to third parties without Our prior written consent.
• You acknowledge and agree that, except as noted above, we will advertise your donated Sample under a fictitious name to help protect your identity.
Consent to use of childhood photos on Premier website: _______Initials
Consent to use of adult photos on Premier website: _______Initials
4. Donation Process: Your sperm will be collected by masturbation in one of Our donor cabins at Our offices, and processed by trained professionals in accordance with established procedures and protocols. You acknowledge that Premier has established policies on donation criteria, which Premier reserves the right to change upon immediate notice at any time, that You agree to respect and with which You agree to comply. Although the Sample donation process is generally safe, You acknowledge and assume the risk of any medical problems that might arise out of the donation process, and agree to disclose any issues to Premier and to seek medical care immediately, including calling 9-1-1 if necessary and appropriate.
5. Identification of Donor: Each time You arrive at Our offices for purposes of providing Your Donation, You will submit to a fingerprint reader. We will use the fingerprint scan to verify Your identity and link it to Your Sample for freezing purposes.
6. Ownership and Use of Samples: You acknowledge and understand that your rights, title, and interest in donated Sample are strictly as set forth in the Premier Donor Agreement and herein. You acknowledge and assume the risk of mental, emotional, psychological distress that may arise out of donating and the implications thereof, and agree to disclose any questions regarding such risks to Premier and to seek medical or mental health professional support if warranted.
7. Withdrawal of Consent: You understand that You may withdraw all of the above consents and discontinue Your donations and participation at any time without any adverse legal or financial consequences regarding the donations already made. However, Your right to withdraw the above consents will apply on a “going forward” basis and exists up until the time that any specific Recipient has begun an assisted reproduction cycle in reliance on the availability of Your Sample. The withdrawal will not undo or require any action regarding past data collection, testing, or donation of Samples to such Recipients. Any of Your remaining Samples in Premier’s possession will no longer be released to Recipients. As a withdrawal of Your consent, You are responsible for any costs associated with the destruction or return of Your Samples to You.
8. Financial Considerations: You understand that Sample Donation is a voluntary activity and that California law does not allow Donors to receive monetary compensation other than reasonable reimbursement of expenses incurred, which Premier reserves the right to update at its sole discretion. Reimbursement terms are described in the Donor Agreement.
9. Legal Review: You acknowledge that You have been advised to seek independent legal counsel to review and explain the terms of this Informed Consent Form before signing.
EXPRESS AND KNOWING CONSENT
Please read and initial next to each statement below:
_____ I have carefully reviewed and understand the above Informed Consent.
_____ I have been encouraged to ask questions, I have had sufficient opportunity to discuss the issues described with a Premier representative, and I have had all of my questions answered to my satisfaction.
_____ I am not aware of any present and current limitation on my mental or physical capacity that would limit my ability to sign this consent form. I do not require any conservator, guardian or other authorized agent to sign this consent. I have the capacity to sign this consent form.
______ I acknowledge I have the opportunity not to proceed and am choosing to authorize Premier to commence the Sample donation process by signing below.
NOTE: DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND FEEL THAT YOU UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE BEFORE SIGNING THIS FORM. DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR MENTAL ABILITIES OR IF YOU FEEL RUSHED OR UNDER PRESSURE.
I CONSENT TO SPERM SAMPLE DONATION AND THE ABOVE LISTED ITEMS. I CERTIFY THAT I HAVE READ THIS INFORMED CONSENT, DISCUSSED THE ISSUES NOTED ABOVE, HAD OPPORTUNITIES TO ASK QUESTIONS, AND AGREE AND ACCEPT ALL OF THE TERMS ABOVE.
Date: ____________
Donor Name: _____________________ Donor Signature: _____________________
Witness
I have explained this Informed Consent and answered all questions, and I have informed the patient of the available alternatives and of the potential risks. To the best of my knowledge, the patient has been adequately informed and has consented.
Name: ______________________________
Signature: ___________________________ Date: ________________
DONOR AGREEMENT
This Donor Agreement (the “Agreement) between Premier Sperm Donors LLC (“Premier,” “We,” “Our,” and “Us”) and the Donor identified below (“Donor” or “You”) is entered into as of the date indicated below (the “Effective Date”) in connection with Your donation (“Donation”) to Premier’s Sperm Donor Program of sperm sample(s) (“Sample(s)”) for use by third party recipients for purposes of assisted reproduction (“Recipient(s)”). Premier and Donor are referenced below as a “Party” or, together, as the “Parties”. The Agreement is intended to set forth the terms agreed to between the Parties related to Donor’s donation of a Sample, as to which the Parties hereby agree as follows.
1. Sperm Donation. Donor understands and acknowledges that the main objective of Donation is to enable a Recipient who would otherwise not be able to do so to have children and experience parenthood via assisted reproduction. Donor enters into this agreement to protect the interests of everyone involved, including Donor, Recipient, any children resulting from Donation, Premier and its affiliates, agents, and representatives. Donor hereby consents to Donation for assisted reproductive purposes under the terms set forth below. Donor agrees to be bound by and comply with all Program Rules, as adopted in Premier’s sole discretion from time to time.
2. Compensation. Donor understands and acknowledges that Donation is a voluntary activity for which monetary compensation is prohibited for any Sample or any exchange of rights, and that compensation is exclusively permitted, intended, and provided as reimbursement for Donor’s time, inconvenience, expenses, and lost wages in connection with the sperm donation procedure. Premier reimburses Donors at such rates as Premier determines to be reasonable from time to time (currently $150 for each Donation that meets Premier criteria ($60 paid at the time of donation; $60 upon return of satisfactory quality analysis (typically 72 hours), and $30 upon Donor’s scheduled return date for follow-up infectious disease testing)) for up to ten (10) Donations. All compensation shall be treated as taxable income, for which Donor will receive a 1099 tax document and be responsible for paying taxes thereupon. Premier reserves the right to change its fee schedule for reimbursement of Donations and other services in its discretion from time to time.
3. Accurate and Complete Disclosure. Donor acknowledges that Premier requires accurate and complete disclosure of certain personal information and medical, genetic, and infectious disease testing, which Premier is required to maintain. Donor agrees to make accurate and complete disclosure of all requested information and to cooperate fully with all testing required by Premier. Donor acknowledges that all Donors must qualify medically to donate Samples. If Sample quality is deemed satisfactory, Donor will be invited back to complete blood and urine tests for infectious diseases and genetic conditions, followed by consultation with a mental health provider and a genetic counselor. Testing will be at no cost to Donor. Donors who are medically cleared will be invited to proceed with the process. Donor agrees to update Premier regularly as to Donor’s address and contact information, even in the event of the termination of this Agreement. Donor acknowledges that future testing or other legal requirements may render donated Samples to be unusable.
4. Recordkeeping and Confidentiality. Donor acknowledges that Premier will make its best efforts to protect the confidentiality and privacy of Donor (and Recipient(s)) subject to the limitations of law, e.g. where disclosure of information is required by law or this Agreement. Donor acknowledges and agrees that Donor will sign a declaration agreeing to share Donor’s identity to an individual conceived by assisted reproduction with Donor’s Sample, upon request, once such individual reaches 18 years of age. Donor consents to Premier’s maintenance of updated contact information and disclosure of personal data in conformity with legal requirements. Donor agrees to not to disclose any confidential information related to Donor’s Donation or the Sample donation process to third parties without Premier’s prior written consent.
5. Application of Family Code § 7613. With respect to all Donations, Donor acknowledges, notwithstanding any changes in law that may affect this Agreement, Donor hereby irrevocably intends for Recipient of a Donation to have sole legal custody and be the legal parent(s) of any child born using Donor’s Sample with full parental rights and responsibilities to the child and hereby waives all parental rights and responsibilities for children born of a Sample donated to a Recipient. However, this does not limit Donor’s ability to withdraw consent and discontinue donations and participation at any time regarding donations already made, on a “going forward” basis for Sample(s) not already been utilized in reproductive treatments. Donor understands and intends that California Family Code Section 7613, which overcomes the basic presumption of parental rights of both egg and sperm donors, shall apply in all cases of Donor’s donation of Sample(s) to any Recipient. As a result of the foregoing, Donor has no further legal rights regarding the Sample or any child conceived using Donor’s Sample, which all such rights belong to Recipient and not Donor. Donor agrees to cooperate fully in executing such additional documents as needed to establish Recipient’s parental rights as well as the co-parental rights of any other person designated by Recipient. Donor acknowledges that Donor shall not be listed as the father or parent of any child born to a Recipient. Donor agrees not to request, seek, or attempt to compel custody, visitation, guardianship, or other rights and that Donor shall not have parental, custodial, visitation, inheritance, or other rights or obligations with respect to any child born from a Sample donated to a Recipient. Donor waives any rights to decision-making regarding any embryo, pregnancy, or child conceived with a Sample donated to a Recipient. Donor acknowledges that applicable California or federal law may change in the future and alter Donor’s rights and responsibilities, in which case this Agreement will remain in full force and effect except as thereby invalidated or modified. This Section shall survive and remain in full force in the event of termination of this Agreement.
6. Relinquishment of Rights. Donor acknowledges and agrees that all Samples provided are the property of Premier subject only to the rights provided in this Agreement, and are authorized to be used with Donor’s consent for assisted reproduction technology. Donor irrevocably waives all rights and relinquishes all claims to Sample(s) and any biological product thereof, including embryos, pregnancies, or offspring that might result therefrom. Such waiver does not limit Donor’s ability to withdraw consent, as detailed in Section 7 below. Donor waives all rights with respect to fertilization, cryopreservation, transfer, discard, and donation of Samples and/or embryos to third parties for the purpose of conception. This Section shall survive and remain in full force in the event of termination of this Agreement.
7. Withdrawal of Consent. You understand that You may withdraw all of the above consents and discontinue Your donations and participation at any time without any adverse legal or financial consequences regarding the donations already made. However, Your right to withdraw the above consents will apply on a “going forward” basis and exists up until the time that any specific Recipient has begun an assisted reproduction cycle in reliance on the availability of Your Sample. The withdrawal will not undo or require any action regarding past data collection, testing, or donation of Samples to such Recipients. Any of Your remaining Samples in Premier’s possession will no longer be released to Recipients. As a withdrawal of Your consent, You are responsible for any costs associated with the destruction or return of Your Samples to You.
8. No Guarantees. Donor acknowledges that Premier cannot guarantee that the appropriate tests have been performed on any Sample(s) or that tests are fully accurate, leading to an unpreventable risk of disease transmission (as well as inheritable illnesses or inheritable birth defects). Donor acknowledges that, despite Premier’s commitment to use reasonable efforts to preserve, handle, and transport safely Sample(s) for use in assisted reproduction, there are inherent risks in the process, and Premier makes and Donor receives no guarantees of Sample quality or successful use and no guarantees concerning collection, processing, testing, storage, freezing, thawing, and/or shipping. To the maximum extent permitted by appliable law, Premier provides and makes available its service offerings without warranties of any kind, whether express or implied, including, but not limited to, implied warranties of merchantability, fitness for a particular purpose, or non-infringement. No advice or information, whether oral or written, obtained by Donor from Premier will create any warranty not expressly stated herein. This Section shall survive and remain in full force in the event of termination of this Agreement.
9. Limitation of Liability and Damages. Donor agrees that Premier shall not be liable for any claims or damages resulting from use or anything relating to Donations, including without limitation inadvertent or unintentional destruction or wasting of Sample(s). Donor’s sole remedy for dissatisfaction with Premier shall be to terminate this Agreement. Donor agrees that under no circumstance shall any of Premier be liable for any damage resulting from use or inability to use Sample(s). This limitation of liability prevents Donor from asserting claims against Premier based on warranty, contract, tort, strict liability, and any other legal theory, and covers all losses and claims of any type including, without limitation, direct or indirect, special, incidental, reliance, consequential, exemplary, and punitive damages, personal injury, lost profits, or damages resulting from lost data or business interruption. This Section shall survive and remain in full force in the event of termination of this Agreement.
10. Jurisdiction and Dispute Resolution. This Agreement is entered into and performed in the State of California, and shall be governed by and shall be construed under the laws of California. If a dispute of any kind arises, the Parties agree to submit the dispute to binding arbitration. If any provision of this arbitration agreement is found unenforceable, the unenforceable provision shall be severed, and the remaining arbitration terms shall be enforced (but in no case shall there be a class arbitration). All Disputes shall be resolved finally and exclusively by binding individual arbitration with a single arbitrator administered by JAMS, Inc. according to this provision and the applicable arbitration rules for that forum. The Federal Arbitration Act, 9 U.S.C. §§ 1-16, fully applies. The arbitrator’s award shall be final, binding, and conclusive on the parties and may be entered as a judgment in any court of competent jurisdiction. In the interest of efficiency, the arbitrator shall limit discovery to as minimal as possible in the arbitrator’s discretion. The arbitrator shall award attorneys’ fees and reasonable expenses to the prevailing party, if any. The parties further agree that this Agreement is intended to be strictly construed to provide for arbitration as the sole and exclusive means for resolution of all disputes hereunder to the fullest extent permitted by law. The parties expressly waive any entitlement to have such controversies decided by a court or a jury. For purposes of this arbitration provision, references to Donor and Premier also include their respective subsidiaries, affiliates, agents, employees, predecessors, successors, and assigns. This Section shall survive and remain in full force in the event of termination of this Agreement.
11. Indemnification. To the extent permitted by law, Donor agrees to defend, indemnify, and hold Premier, its agents, representatives, and employees harmless from all claims, losses, and liabilities (including reasonable attorneys’ fees) to the extent caused by Donor’s breach of this Agreement, negligence, gross negligence, or willful misconduct. Donor holds Premier harmless, releases, and shall defend Premier from any claims (by third parties or otherwise) arising from the Donation or the collection, processing, testing, freezing, thawing, sale, purchase, storage, shipping, release, loss, use, damage or destruction of the Sample(s). This Section shall survive and remain in full force in the event of termination of this Agreement.
12. Complete and Voluntary Agreement. This Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof (excluding the Donor Consent signed by You which remains in force) and supersedes all prior negotiations, statements, and agreements, whether written or oral. No amendments will be valid unless written and signed by all Parties. Anything on Premier’s Website inconsistent or in conflict with the terms of this Agreement is superseded by the terms of this Agreement. You acknowledge that neither Premier nor any Premier representative has made any promise, representation or warranty whatsoever, either express or implied, written or oral, which is not contained in this Agreement for the purpose of inducing You to execute the Agreement, and You acknowledge that You have executed this Agreement in reliance only upon such promises, representations and warranties as are contained herein. You have had the opportunity to discuss thoroughly all aspects of Your rights and this Agreement with an attorney, have carefully read and fully understands all provisions of this Agreement, has been given a reasonable period to consider signing this Agreement, and have the capacity to enter into this Agreement. No provision of this Agreement shall be construed against any party merely because that party or its counsel drafted the provision. You have entered into this Agreement voluntarily, without duress, coercion, or mistake, in consultation with your own attorney, and based upon Your own judgment, and if any fact or matter upon which You now rely later proves to be otherwise, this Agreement shall remain in full force and effect. Nothing in this Section shall limit the right of Premier to make changes in its policies and procedures at any time, which may take effect at any time and shall be binding upon Donor from the time of issuance. This Section shall survive and remain in full force in the event of termination of this Agreement.
13. Term and Termination. This Agreement is effective from the date it is signed by the Parties and shall remain in full force and effect for such time as Premier retains any Sample. It may not be terminated except in a signed writing by all Parties, at which time any Sample remaining in Premier’s possession may be destroyed or returned (at Donor’s expense). All sections of this Agreement which, by their nature are designed to survive expiration or termination of this Agreement, including, but not limited to, indemnity and limitation of liability clauses, shall survive.
14. Event of Misuse. In the event that Premier determines in its sole discretion that Donor has acted abusively with respect to Premier’s Sperm Donor Program (for example, by undergoing testing, receiving reimbursement, and shortly thereafter terminating), Premier reserves the right to seek reimbursement of all amounts paid to Donor and testing expenses, and shall be entitled to recover such costs incurred as a result of Donor’s abuse. This Section shall survive and remain in full force in the event of termination of this Agreement.
15. Severability. The provisions of this Agreement are severable. If any provision is held to be invalid, void, or unenforceable, it shall not affect the validity or enforceability of any other provision, in which case the remaining provisions not so declared shall nevertheless continue in full force and effect, but shall be construed in a manner so as to effectuate the intent of this Agreement as a whole, notwithstanding such stricken provision(s). In lieu of any stricken provision(s), there will be added automatically as a part of this Agreement a legal, valid and enforceable provision as similar in terms to such illegal, invalid or unenforceable provision as may be possible.
16. No Third Party Beneficiaries. Except as expressly provided otherwise, there are no third party beneficiaries to this Agreement and nothing contained in this Agreement is intended to or shall be interpreted to create any third-party beneficiary claims.
17. Waiver. No waiver of any provision of this Agreement shall be deemed a further or continuing waiver of such term or condition or any other term or condition.
18. Notices. Donor agrees that Premier may provide any and all notices to Donor by e-mail as well as by any other reasonable method. Any notice delivered by Donor to Premier under this Agreement shall be delivered by contacting Premier via info@psdonors.com.
19. Force Majeure. The failure of Premier to comply with this Agreement because of an act of God, war, fire, riot, terrorism, pandemic, earthquake, power failure, actions of federal, state or local governmental authorities or for any other reason beyond the reasonable control of Premier, shall not be deemed a breach of this Agreement. If Premier fails to act with respect to Donor’s breach or anyone else’s breach on any occasion, Premier is not waiving its right to act with respect to future or similar breaches.
20. Successors and Assigns. You agree that you have not heretofore and shall not assign, transfer or grant, or purport to assign, transfer or grant, any of the rights, obligations or matters agreed upon by this Agreement without Premier’s prior written consent. In the event of Donor’s death, all rights of Donor under this Agreement shall terminate and Premier shall have the right but not the obligation to discard, dispose, or otherwise handle Donor’s Sample(s) in the manner deemed appropriate. Premier may assign all or part of this Agreement. This Agreement is binding upon, and shall inure to the benefit of the successors and assigns of Premier, its successors, assigns, affiliates, and representatives. This Section shall survive and remain in full force in the event of termination of this Agreement.
Agreed as of the Date Signed Below:
Signing below constitutes acknowledgement that You have read and understand the information provided in this Agreement, that any questions have been satisfactorily answered, and that You voluntarily, willingly and freely consent and agree to participate in Premier’s Sperm Donor Program.
DATE ______________________________
DONOR
Signature _____________________________
Name Printed__________________________
PREMIER SPERM DONORS
Signature _____________________________
Name Printed__________________________
Title _________________________________
SPERM DONOR PROGRAM REQUIREMENTS
In order to donate sperm, Donor agrees to do the following:
A. Provide true, complete, and accurate medical, genetic, and social history.
B. Sign any and all releases needed to allow the Sperm Donor Program to obtain past medical records, as well as medical records related to the outcome of sperm donation.
C. Sign consent for background check.
D. Sign a declaration (attached herein as Exhibit “A”) agreeing to share Donor’s identity to an individual conceived by assisted reproduction with Donor’s Sample, on request, once the individual reaches 18 years of age.
E. Be available on the date and attend all appointments, follow-up tests and sperm collection.
F. Undergo medical screening including but not limited to physical examination, blood and urine tests, testing for infectious diseases, and testing for genetic disorders.
G. Meet with a designated mental and genetic health professional of the Sperm Donor Program’s designation for consultation and testing.
H. Comply with all instructions including any further examinations or testing which the Sperm Donor Program deems necessary.
I. Refrain from excessive use of alcohol, tobacco, or vaping products.
J. Refrain from using illegal drugs or Testosterone while participating in the Sperm Donor Program.
K. Agree to be contacted in the future by the Sperm Donor Program in the event the sperm recipient(s) or child(ren) needs medical information.
L. Keep the Sperm Donor Program informed of any changes to your contact information.
M. Notify the Sperm Donor Program immediately of any changes in your health or medical condition or any newly discovered information while participating in the Sperm Donor Program.
N. Notify the Sperm Donor Program immediately of any newly discovered information in yourself or your family about any inheritable or communicable medical condition, or a condition which would in any other way potentially affect the child(ren) born of your donation.
O. Follow all medical instructions given to you by the Sperm Donor Program.
EXHIBIT “A” – DECLARATION TO DISCLOSE IDENTIFYING INFORMATION
Pursuant to Health and Safety Code §1644.2(b) I understand that it is Premier Sperm Donors LLC’s policy to require Donor to sign the foregoing Declaration to Disclose Identifying Information to participate in Premier’s Sperm Donor Program.
A. Donor hereby agrees to disclose Donor’s Identifying Information to any individual conceived by assisted reproduction utilizing Donor’s Sample once such individual attains 18 years of age and requests such information.
B. “Identifying Information” shall include Donor’s full name, date of birth, permanent address, current address, telephone number, e-mail address, and any other contact information provided at the time of donation.
C. Donor agrees to inform Premier Sperm Donors LLC of any changes or updates to their Identifying Information.
D. As additional consideration to Premier Sperm Donors LLC, the undersigned releases Premier Sperm Donors LLC, its officers, directors, employees, volunteers, agents, and representatives from any and all claims that the undersigned may at any time have against any of them that result or arise from Premier Sperm Donors LLC’s release of the information requested by this Declaration. Further, the undersigned agrees to indemnify Premier Sperm Donors LLC, and hold it harmless from and against all claims, demands, liabilities, and expenses (including reasonable attorney’s fees) that result or arise from the release of such information.
The undersigned consents to the release of the following Identifying Information:
Full Name:
Date of Birth:
Permanent Address:
Current Address:
Telephone Number:
E-mail:
Other:
Donor
I declare under the penalty of perjury under the laws of the State of California that I have read and understand the above statements and have the legal capacity to sign this Declaration.
Name: ______________________________
Signature: ___________________________ Date: ________________
Attestation of Witness
On (date) before me, (Donor) personally appeared who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity, and that by his/her/their signature on the instrument the person executed the instrument. I explained the contents of this declaration and answered all questions. To the best of my knowledge, Donor has understood and consents to the contents of this declaration.
I certify under penalty of perjury under the laws of the State of California that the foregoing paragraph is true and correct.
Witness Name: ______________________________
Signature: ___________________________ Date: ________________
CONSENT TO COLLECTION OF BIOMETRIC INFORMATION AND SENSITIVE PERSONAL INFORMATION
This Consent has been prepared to help inform you as a potential donor (“You,” “Your,” or “Donor”) about the collection of biometric information and sensitive personal information by Premier Sperm Donors LLC (“Premier,” “We,” “Our,” and “Us”) in connection with Your donation (“Donation”) to Premier’s Sperm Donor Program of sperm sample(s) (“Sample(s)”) for use by third party recipiences for purposes of assisted reproduction. It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page, and sign the consent for the information collection described below.
1. Definitions:
a. “Biometric Information” refers to an individual’s physiological, biological, or behavioral characteristics, including an individual’s deoxyribonucleic acid (DNA), that can be used, singly or in combination with each other or with other identifying data, to establish individual identity. Biometric information includes, but is not limited to, imagery of the iris, retina, fingerprint, face, hand, palm, vein patterns, and voice recordings, from which an identifier template, such as a faceprint, a minutiae template, or a voiceprint, can be extracted, and keystroke patterns or rhythms, gait patterns or rhythms, and sleep, health, or exercise data that contain identifying information.
b. “Sensitive Personal Information,” as defined in California Civil Code § 1798.140, is information that reveals the following:
(1) A consumer’s social security, driver’s license, state identification card, or passport number.
(2) A consumer’s account log-in, financial account, debit card, or credit card number in combination with any required security or access code, password, or credentials allowing access to an account.
(3) A consumer’s precise geolocation.
(4) A consumer’s racial or ethnic origin, religious or philosophical beliefs, or union membership.
(5) The contents of a consumer’s mail, email, and text messages unless the business is the intended recipient of the communication.
(6) A consumer’s genetic data; or
(1) The processing of biometric information for the purpose of uniquely identifying a consumer;
(2) Personal Information collected and analyzed concerning a consumer’s health; or
(3) Personal Information collected and analyzed concerning a consumer’s sex life or sexual orientation.
2. Biometric Information Privacy Statement: Premier will not sell, rent, or trade your Biometric Information. Your Biometric Information will only be used by Premier to verify your identity in accordance with the guidelines published by the National Institute for Standards and Technology, as required for the prevention of fraud, and for purposes of properly storing any Sample as part of your participation in Premier’s Sperm Donor Program. Premier will transfer your Biometric Information only when required by a subpoena, warrant, or other court ordered legal action.
Participation in Premier’s Sperm Donor program will include collection of Your fingerprint information, including fingerprint or hand scanning, which will be used for the purposes of identity verification and storing Your Sample.
3. Notice and Consent: This Notice and Consent for the collection of Biometric Information, Personal Information and Sensitive Personal Information (“Consent”) describes how Premier collects and processes certain categories of Personal Information in connection with Premier’s Sperm Donor Program.
Please carefully review the details below prior to consenting to our collection and use of your information. Please note that once consent has been provided for the collection and processing of your information as part of your verification it may not be revoked where it is required to complete storage of your Sample in connection with Premier’s Sperm Donor Program.
By initialing here and signing below, you authorize our collection and use of your biometric information and personal sensitive information for the purposes described herein.
INITIALS: ______________
Express and Knowing Consent
Please read and initial next to each statement below:
_____ I have carefully reviewed and understand the above Consent.
_____ I have been encouraged to ask questions, I have had sufficient opportunity to discuss the issues described with a Premier representative, and I have had all of my questions answered to my satisfaction.
_____ I am not aware of any present and current limitation on my mental or physical capacity that would limit my ability to sign this consent form. I do not require any conservator, guardian or other authorized agent to sign this consent. I have the capacity to sign this consent form.
______ I acknowledge I have the opportunity not to proceed and am choosing to authorize Premier to commence the Sample donation process by signing below.
NOTE: DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND FEEL THAT YOU UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE BEFORE SIGNING THIS FORM. DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR MENTAL ABILITIES OR IF YOU FEEL RUSHED OR UNDER PRESSURE.
I CONSENT TO COLLECTION OF BIOMETRIC INFORMATION AND PERSONAL SENSITIVE INFORMATION LISTED ABOVE. I CERTIFY THAT I HAVE READ THIS CONSENT, HAD OPPORTUNITIES TO ASK QUESTIONS, AND AGREE AND ACCEPT ALL OF THE TERMS ABOVE.
Date: ____________
Donor Name: _____________________ Donor Signature: _____________________
Witness
I have explained this Consent and answered all questions, and I have informed the patient of the available alternatives and of the potential risks. To the best of my knowledge, the patient has been adequately informed and has consented.
Name: ______________________________
Signature: ___________________________ Date: ________________
