Surgery Fund Application Form

Point of Pride Surgery Fund Application

Point of Pride’s Annual Transgender Surgery Fund is a scholarship-like program that provides direct financial assistance to trans folks who cannot afford their gender-affirming surgery.
We strongly recommend that you read over the program page and requirements before applying: https://www.pointofpride.org/annual-transgender-surgery-fund
Your name: (as you wish to be addressed)*

First NameLast Name
Your email:*
example@example.com
Your phone number*
What pronouns do you use?*

He/Him/HisHy/Hym/HysShe/Her/HersThey/Them/TheirsXe/Xem/XyrZe/HirNoneWrite In my Own
Country*
Location*

Street Address

Street Address Line 2

CityState

Zip Code
What research or preparations have you made, or what steps have you already taken, to prepare for travel to the United States for surgery?*

Please note any research or action you've taken regarding travel considerations such as your visa/passport, transportation, and lodging. You must also note what you anticipate your postoperative care plans will look like, including who will accompany you for surgery. (If you anticipate any challenges in traveling to the US, be sure to also explain them here.)0/800
Support Person
Some applicants need extra support with their application due to language barriers, disability, inconsistent access to Internet, or other factors. If you'd like to name a support person, you may do so below. Both you and your support person will be included on all emails regarding your application, so it's important that you select a support person that you trust.

If you'd like to revoke or update your support person at any time, you may contact surgeryfund@pointofpride.org to do so. Naming a support person is optional and will not positively or negatively affect your application status. If you do not wish to name a support person, please skip this section.

We encourage you to ensure that you have the consent of your chosen support person before including their contact information on your appliation.
Support person's name:

First NameLast Name
Support person's email:
example@example.com
This is the same email address you listed for yourself above. We recommend providing a different email address for your support person.
Support person's phone number
This is the same phone number you listed for yourself above. We recommend providing a different phone number for your support person.
Your relationship to your support person*

Accessibility supportEmotional supportTechnological/Internet supportTranslation supportOther
Demographic Info

The information collected in this section helps us identify additional grant and partnership opportunities, and better serve our applicants and community. Your responses will not affect your eligibility for this (or any other) Point of Pride program.
Your gender identity:*

AgenderAndrogynousBigenderDemifemale/DemigirlDemimale/DemiboyGender Fluid/ Gender Queer/ GenderfluxGender Non-Conforming (GNC)IntersexNon-Binary (NB; Enby)Questioning/UnsureTrans Female (MtF; Male to Female; AMAB)Trans Male (FtM; Female to Male; AFAB)TransfeminineTransmasculineTwo-SpiritWrite In my Own
Your age:*
Please note our program requires that all applicants are 18 years of age by the date of their surgery.
Your ethnicity origin:*

Aboriginal; Indigenous; Native; Native American/First NationsAsian; Pacific Islander; South-East Asian; IndianBlack or African AmericanHispanic or LatinxMiddle EasternWhitePrefer not to discloseWrite In my Own
Your veteran/military status:*

I am a US military veteranI am an active-duty US service memberI am not a member of the US militaryMy parent/guardian is a US military veteranMy parent/guardian is an active-duty US service memberMy partner/spouse is an active-duty US service memberPrefer not to disclose
Are you a student?*

Yes - US Resident, In-State StudentYes - US Resident, Out of state StudentYes - US Resident, Studying InternationallyYes - International Resident, Studying in the USYes - International Resident, Studying within my home countryYes - International Resident, Studying outside of my home countryNo
What is the PRIMARY way you pay tuition?*

Self PayParent/Family PayFinancial Aid or GrantsStudent Loans
Do you have any long-standing illness, disability, or infirmity? (Long-standing means anything that has troubled you over a period of time or that is likely to affect you over a period of time.)*

YesNoPrefer not to disclose
Have you applied for, or do you currently receive, government disability benefits (SSI/SSDI or your country's equivalent?)*

I receive government disability benefitsI've applied for government disability and am awaiting official determinationI've applied for government disability and my benefits were deniedI have chosen not to apply for government disability benefitsPrefer not to disclose
Are you the primary caretaker for another individual?*

Yes - A minor child or childrenYes - A disabled parent or older adultYes - A disabled partner or spouseNoPrefer not to disclose

Are you currently, or have you ever experienced...*

	Yes - Currently	Yes - In the Past	No - Never	Prefer not to disclose
homelessness or housing insecurity?
discrimination by your healthcare provider?
discrimination by an employer?
incarceration?

Short Answer Responses

In this section, try to be as detailed and specific as you can. Please keep each response to 800 characters or less.
Describe your current financial situation.*

This question impacts our decision-making process more than any other response. We ask this question to understand the expenses and circumstances that have created your financial need, as well as your lack of access to outside support.0/800

Describe all attempts you have made before to afford gender-affirming care, including savings, fundraising, or insurance.*

We ask this question to understand what steps you have taken in your healthcare journey, and that you fully understand the financial roadblocks unique to your situation and have exhausted different potential solutions to overcome them.0/800

Describe your preparations for surgery and post-operative care: any research you have done, any consultations you have had, and/or how you selected your preferred surgeon (if applicable) and/or your postoperative considerations.*

We ask this question to assess how far along you are in your healthcare journey and how well you understand everything surgery will entail. If you are traveling for surgery or if you are living in an unsupportive environment, please include details about how you will navigate potential challenges.0/800

Tell us something else about yourself.*

Each of us is so much more than just our trans identity. We ask this question because we want to have a better understanding of who you are as a person. Without sharing identifying information, tell us: what makes you, you?0/800

Point of Pride Surgery Fund Application

Support Person

Demographic Info

Annual Trans Surgery Fund Application

About Your Surgery

Short Answer Responses

Before You Submit

By clicking the button below, you submit your application. You will not be able to edit or update your application once it is submitted.