NIAW Grant Application

Grant Application
PLEASE READ!

Eligibility: In order to be considered for a grant, application must be completed, and a detailed history about fertility issues attached.
The grant amounts will be dependent on fundraising efforts the previous year. While we would love to offer grants to every applicant, not all applicants will receive grants. The grant amounts vary among the grant recipients, and partial and full grants may be awarded. What is covered (i.e. monitoring, lab work, medications, procedures, etc.) under the grant amount will be disclosed to each of the grant recipients at time of award and funds from the grant will be given directly to the clinic. The funds from the grant will be available to the recipients for a period of twelve months. The grant can be used toward fertility treatments at any fertility clinic that is a member of the Society for Assisted Reproductive Technology (SART).

All information submitted in this application is strictly confidential and will be protected with the highest level of discretion. Any information disclosed will be used solely for the intended purpose of evaluation. We will not share, distribute, or disclose any details to unauthorized parties under any circumstances, except as required by law. Your privacy is our priority, and we are committed to safeguarding your personal information at all times.
SUBMISSION CHECKLIST:

To apply for a grant, you must submit the following information with your completed application:

1. Complete application. Write N/A (Not Applicable) if the question does not apply to you. Do NOT leave it blank. ALL fields MUST be filled in.
2. A personal statement indicating why you (and your spouse) have chosen to apply for a SIF grant. Include information about your efforts to conceive, your financial circumstances, and why you feel you would be a worthy candidate. Photos are welcomed, but not mandatory.
3. Application MUST have a signature(s)
4. ALL APPLICATIONS MUST BE IN OUR HANDS BY THE GRANT DEADLINE. NO LATE SUBMISSIONS WILL BE ACCEPTED.

5. Application fee of $50. This fee is NONREFUNDABLE. Paypal or Credit Card only.
Applicant

"Applicant" refers to the person who will be receiving the embryo implantation
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth
Employer Name
Date Employment Began
Job Title
Applicant's Profession
Have you ever been convicted or pled guilty to a felony or misdemeanor? If yes, please give the date of the offense, the charge, and the outcome.
Applicant's Partner Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Date of Birth
Employer
Date of Employment
Job Title
Co-Applicant's Profession
Have you ever been convicted or pled guilty to a felony or misdemeanor? If yes, please give the date of the offense, the charge, and the outcome.
Children Living in your Home

Please list name, date of birth and biological parents
Name, DOB, Biological Parents
Health Insurance Information
Primary Insurance Provider
Member Number
Secondary Insurance Provider
Member Number
Does your insurance provide fertility benefits?
Insurance explanation, if needed
Medical Information
Clinic Name
Physician's Name
Clinic Address
Telephone
Diagnosis and Treatment received to date
How long have you been trying to conceive?
Infertility Diagnosis - You may choose multiple

Other
Diagnosis Explanation, if needed
Has the applicant ever been pregnant? If so, how many times?
How many live births? How many losses?
Please list any infertility procedures and outcomes
What is the Doctor's recommendation for treatment?
Total Approximate Cost
Do you have any frozen embryos?
Amount of Grant Requested
Photo and Personal Story Uploads
Please upload your personal story

Browse Files

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Any additional files you would like to send

Browse Files

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Confidentiality Agreement
All information submitted in this application is strictly confidential and will be protected with the highest level of discretion. Any information disclosed will be used solely for the intended purpose of evaluation. We will not share, distribute, or disclose any details to unauthorized parties under any circumstances, except as required by law. Your privacy is our priority, and we are committed to safeguarding your personal information at all times.
Signatures and Application Fee
Applicant's Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Co-Applicant's Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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Application Fee$50.00
Non-refundable fee

Donation$10.00
Additional donation to Starfish Infertility Foundation

Donation Amount

Total $0.00
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Grant Application

Applicant

Applicant's Partner Information

Children Living in your Home

Health Insurance Information

Medical Information

Photo and Personal Story Uploads

Confidentiality Agreement

Signatures and Application Fee

My Products