GAS Fund Application
Name of Applicant (legal name not required at this stage)
*
First Name
Last Name
Name of applicant support (translator, tech assistance, etc)
First Name
Last Name
Relationship of support to applicant
Please Select
Translator / Interpreter
Technological assistance
Peer support
Applicant Email
*
Confirmation Email
example@example.com
Applicant Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Applicant support email
Confirmation Email
example@example.com
Applicant Zip code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
*
-
Month
-
Day
Year
Date
How would you describe your gender identity
*
Trans woman
Cis woman
Trans feminine
Trans man
Cis man
Trans masculine
Nonbinary
Agender
Genderfluid
Gender non-conforming
Other
Do you identify as intersex
*
Yes
No
Unsure
What best describes you race / ethnicity
*
White / Caucasian
Black / African American
Indigenous or Native American
Native Hawaiian or Pacific Islander
East Asian
Southeast Asian
South Asian
Arab
Latine / Latinx
Do you have any long standing illness, disability or infirmity? (Long-standing in this case means anything that has troubled you over a period of time or that is likely to affect you over a period of time.)
*
Yes
No
Unsure
Are you currently a student?
*
Yes, full time
Yes, part time
No
Are you a veteran?
*
Yes
No
Are you a full time caregiver of another individual(s)
*
Yes
No, but I am a part-time caregiver
No
Are you the primary source of income for your household?
*
Yes
No
I am the only individual in my household
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Which tier are you applying for?
*
Please Select
Tier 1 (up to $250)
Tier 2 ($251-500)
Tier 3 ($501-1000)
How much are you applying for?
*
What type of support are you applying for?
*
Rent / bill support during recovery
Prostheses or wigs
Medical tattooing
Transportation support
Hair removal
Other
Please write a short description of what you're seeking
*
Have you gotten any quotes or estimates? (if applicable)
Are you receiving any other funding or financial support for what you're seeking?
*
Is receiving this funding time sensitive (please note we cannot guarantee fund dispersal prior to June 30, 2026)
*
Will this be a one time or ongoing expense?
*
One time
Ongoing
What is your income range?
*
under 20,000
20,000-50,000
51,000-99,000
more than 100,000
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How will these funds help you? What quality of life changes do you expect to see from receiving these funds?
*
What barriers have prevented you from accessing the support / care that you are seeking? (Please include if there's anything not captured by our application)
*
If you have a community support letter please attach it here
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