qSPF Gender Affirming Care Grant Application

GENDER AFFIRMING CARE GRANTS

Applications due Feb 27th
qSPF is providing Gender Affirming Care (GAC) Grants to 24 trans* people each year who live in the Greater Seattle Area, WA. These grants must be used toward covering the costs of gender affirming surgery. Trans* people have less access to health insurance, sick pay, and family support making it much more difficult to plan and pay for gender affirming surgeries. qSPF’s intention with these grants is to provide support to those who need it most.

Cheer Grant

Each quarter, 1 grant for $5,000 will be issued.

This grant is named after Cheer Seattle for their generous donation of $40,000, underwriting the entire first year of GAC Grants. Thank you, Cheer Seattle!

Joy Grant

Each quarter, 5 grants for $1,000 will be issued.

This application is for both grants.

If you have any questions or need any assistance with this application, please email infoqspf@gmail.com
General Information

This will help us determine your eligibility.
To be eligible for a Gender Affirming Care Grant you must
- Identify as trans (including transexual, transgender, nonbinary, two spirit, agender, and all non-cis identities)
- Be 18yrs or older
- Live in the Greater Seattle Area
- Be actively planning a gender affirming surgery
Name on legal documents*

First NameLast Name
Preferred Name if different than above

First NameLast Name
What are your Pronouns?*
Phone Number*
E-mail*
Enter E-mail Here
Address of Residence (must be in Greater Seattle Area / Tacoma to qualify)*

Street Address

Apt/Unit #

CityState

Zip Code
Do you identify as a trans*? (*transgender, transexual, genderqueer, nonbinary, two spirit, or any non-cis identity)*

YesNo
Are you 18yrs or older?*

YesNo
Are you planning a gender affirming surgery or procedure?*

YesNo
Information about your Surgery (5 Points)
Points range from

5 points for
- a set surgery date
- no insurance coverage, and
- high cost of surgery
to 1 point for
- no surgery date
- insurance covers most of the costs
- low out of pocket costs
What surgery or procedure are you applying for assistance with?*
What is the date of your surgery or procedure? If you have not booked it, please enter “NA”*
Do you have health insurance that covers all or part of this surgery? *

YesNo
What is the estimate for how much your surgery will cost you out of pocket?*
Employment Information (5 Points)
Points range from

5 points for
- income of 0-$30,000
- unemployed or under-employed
- no access to paid time off(PTO) or Washington Paid Family and Medical Leave(WPFML)
to 1 point for
- income over $100,000
- stable employment
- qualifies for PTO and WPFML
Yearly Income:*
Are you currently employed?*

YesNo
Tell us a little bit about your employment history over the last 2 years. How consistent/stable has your employment been? *
Recommended Word Count of Approx. 200
Does your employer provide paid time off?*

YesNo
If so, how much paid time off will you be able to use during your recovery time?
Do you qualify for Washington Paid Family and Medical Leave? To qualify your employer must pay into the program, and you must have worked for that employer for at least 820 hours in the last 5 quarters. Check with your HR department and https://paidleave.wa.gov/ if you’re unsure. *

YesNo
Financial Context (5 points)
Points range from

5 points for
- a long recovery time
- no financial support from family or significant others
- low savings
- financial dependents
- other financial burdens
to 1 point for
- short recovery time
- robust financial safety net
- high savings
- no financial dependents
- no other financial burdens
- missing information
How much time will you have to take off of work to recover? *
Please specify in days, weeks, or months.

Use the chart below to calculate how much you will need to cover your basic living costs during recovery. (For example, if you are taking 2 weeks off of work, please enter half a month’s rent into the rent category and calculate 2 weeks worth of all categories) *

	Notes	Amount
Rent
Utilities
Food
Other

Total living costs during recovery*
Auto calculates from the table above
Please describe your financial context. Be sure to answer the following:
- How much have you saved towards your surgery so far?
- Do you receive financial support from your family? Would they contribute to your surgery fund if asked? If so, how much?
- Do you receive financial support from your significant other(s)? Would they contribute to your surgery fund if asked? If so, how much?
- Do you financially support anyone, child or adult? How much does this cost you?
- Do you have other financial burdens that we should be aware of? Do you have other medical concerns or debts? Do you have student loan debt? Do you have any other types of debt?
Feel free to answer in bullet points or paragraph form
Optional Personal Statement (0 Points)

Not scored, but will be taken into consideration.
What excites you most about life after surgery?
Any additional info that you’d like to provide?
Public Announcement (not scored)

Will not impact your chances of receiving the grant.
If you receive this grant would you like your name and image to be publicly announced on social media? (We do not use this question to assess eligibility, so please feel free to remain anonymous if you wish)*

Yes, share my name and imageNo, I prefer to remain anonymous
If you are comfortable with a public announcement, please upload an image that you’d like us to use.

Cancelof
Photo Credit if applicable
Name of the person who took the photo

GENDER AFFIRMING CARE GRANTS

General Information

Information about your Surgery (5 Points)

Employment Information (5 Points)

Financial Context (5 points)

Optional Personal Statement (0 Points)

Public Announcement (not scored)

Demographic Questions