Grant Application Please enable JavaScript in your browser to complete this form. - Step 1 of 3Name *FirstLastAge *Partner (if applicable)FirstLastAgeAddress *Address Line 1CityState / Province / RegionPostal CodeSelect CountryCanadaUnited States of AmericaPhone *Email *EmailConfirm EmailTell us your story (1,000 words or less)Photo Upload (JPG, JPEG, PNG, or BMP) Click or drag files to this area to upload. You can upload up to 2 files. Maximum file size is 2MB.NextMedical InformationAre you currently undergoing fertility treatment? *YesNoWhen did you start?When do you plan to start?Do you have a fertility clinic selected? YesNoWhat is the name of your fertility clinic?What is your doctor's name?Leave blank if not yet assignedWould you like a referral?YesNo, I will select my own clinicDo you have Health Insurance? *YesNoDoes your insurance cover fertility treatment?YesNoInsurance ProviderMember #PhoneDoes your partner's insurance cover fertility treatment?YesNoPartner's Insurance ProviderMember #PhoneHow long have you been trying to conceive?Have you ever been pregnant?YesNoWhen?What is your history with infertility?Include past procedures/treatments (IUI, IVF, etc)Have you or your partner ever been diagnosed with any of the following?Bipolar DisorderCancerHepatitisHIVDepressionDiabetesHeart DiseasePersonality DisorderOtherOther:What medications do you currently take?What medications does your partner currently take?NextApplication Fee *Price: $ 60.00Early Registration Fee *Price: $ 45.00Past Applicant Registration Fee *Price: $ 35.00Referral CodeLeave blank if not providedCredit Card *CardName on CardSignature *Clear SignatureThere is a $60 fee for each application submitted. This fee is non-refundable. The application fee is considered a donation and the foundation will provide a receipt to document the donation. All information submitted to Gift of Parenthood will be held in strictest confidence and viewed only by the selection committee. The Applicant hereby assigns and grants the Organization and its legal representatives the irrevocable and unrestricted right to use excerpts in whole or in part from the Applicant’s personal statement for editorial, trade, advertising, or any other purpose and in any manner and medium; to alter the same without restrictions; and to copyright the same. The Applicant hereby releases the Organization and its legal representatives and assigns from all claims and liability relating to said excerpts. Any person mentioned in Applicant’s personal statement shall be deemed to have consented to the use of their name, image, or likeness by Applicant and/or Organization and Applicant shall defend and indemnify the Organization from and against any claims that any of Applicant’s friends, family or other persons mentioned in the personal statement may assert against the Organization arising from, or related to, the use of any name, image, or likeness of Applicant’s friend, family or other person mentioned in the personal statement by Organization. Surnames will NOT be used so as to protect the identification of any of the above. CommentSubmit