Stardust Grant Application

1
I'm applying for a grant for* This field is required.Please note: this application is NOT intended for oncofertility grants (fertility preservation for cancer patients). If you are interested in an oncofertility grant please see the Sharsheret oncofertility page on our website and submit a separate application
Please Select
Please Select
Intrauterine Insemination (IUI)
A Full IVF Cycle (Egg Retrieval & Embryo Transfer)
Frozen Embryo Transfer (FET) Only
Surrogacy
Other
2
If other, please describe what you are applying for
3
Are you applying with a partner?* This field is required.
Yes
No
4
How did you hear about Stardust?* This field is required.
Please Select
Please Select
Fertility Clinic
Friend/Family
Social Media
Website/Search
Synagogue Referral
Physician Referral
Stardust Event
Other
5
Which fertility clinic referred you?
6
Name of the doctor or professional who referred you
7
Who specifically told you about us?
8
Are you a former Stardust IVF grant recipient?* This field is required.
Yes
No
9
Have you previously applied for a Stardust grant?* This field is required.
Yes
No
10
Full Name* This field is required.
First Name
Middle Name
Last Name
11
Email Address* This field is required.
example@example.com
12
Phone Number* This field is required.
Please enter a valid phone number.
13
Date of Birth* This field is required.
Date
Month
Day
Year
14
Current Age* This field is required.
15
Current Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
16
County or Borough* This field is required.
Please Select
Please Select
Manhattan
Brooklyn
Queens
Bronx
Staten Island
Nassau
Suffolk
Westchester
Rockland
Essex (NJ)
Bergen (NJ)
Union (NJ)
Fairfield (CT)
Other
17
Were you raised Jewish?* This field is required.
Yes
No
18
Do you consider yourself Jewish now?* This field is required.
Yes
No
19
Jewish Affiliation* This field is required.
Please Select
Please Select
Reform
Conservative
Orthodox
Reconstructionist
Unaffiliated
Other
Do Not Identify as Jewish
Not Jewish
20
Synagogue, JCC, or Jewish community organization you're affiliated with (if any).
21
Highest Degree Earned* This field is required.
Please Select
Please Select
High School Diploma
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate
Professional Degree
Other
22
Partner's Full Name* This field is required.
First Name
Last Name
23
Partner's Email Address
example@example.com
24
Partner's Phone Number
Please enter a valid phone number.
25
Partner's Date of Birth* This field is required.
Date
Month
Day
Year
26
Partner's Current Age* This field is required.
27
Was your partner raised Jewish?* This field is required.
Yes
No
28
Does your partner consider themselves Jewish now?* This field is required.
Yes
No
29
Partner's Jewish Affiliation* This field is required.
Please Select
Please Select
Orthodox
Conservative
Reform
Reconstructionist
Unaffiliated
Other
Does Not Identify as Jewish
Not Jewish
30
Partner's Highest Degree Earned* This field is required.
Please Select
Please Select
High School Diploma
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate
Professional Degree
Other
31
Are you currently employed?* This field is required.
Yes
No
32
Current job title
33
How long have you been at your current job?
34
Employer address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
35
Current annual salary
36
Is your partner currently employed?* This field is required.
Yes
No
37
Partner's current job title
38
How long has your partner been at their current job?
39
Partner's employer address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
40
Partner's current annual salary
41
Do you own or rent your home?* This field is required.
Please Select
Please Select
Own
Rent
Live with family
Other
42
Monthly mortgage or rent amount* This field is required.
43
Fertility Clinic Name* This field is required.
44
Doctor / Reproductive Endocrinologist Name
45
List any fertility treatments and year* This field is required.Please list any fertility treatments you have undergone and what year you went through them (put N/A if you have not yet undergone any treatments)
46
How many children do you and/or your partner have?* This field is required.
0
1
2
3+
47
If you have children, how were they conceived?(i.e. naturally, IVF, adoption, surrogacy, etc.)
48
Have you (and partner, if relevant) participated in a genetic screening test yet?* This field is required.
Yes
No
Not sure
49
Approximate amount spent on fertility treatments to date* This field is required.
50
Does either applicant have medical insurance?* This field is required.
Yes
No
51
Has the applicant or partner maxed out fertility coverage?* This field is required.
Yes
No
Not applicable
52
Estimated financial costs still needed* This field is required.Please provide a breakdown of your estimated financial needs (i.e., costs needed to be paid to fertility clinics, agencies, etc. to help you on your journey)
53
If coverage is not maxed out, how much remains?
54
Have you received other grants for past fertility treatments?* This field is required.
Yes
No
55
If yes, please list each grant received, organization, and year
56
Have you applied for other loans, funding, or grants for fertility?
57
Stardust cannot guarantee that it can cover all of an Applicant’s treatment costs. If awarded a partial grant, how will you fund the remainder?* This field is required.
58
Interested in Hebrew Free Loan Society interest-free loan if you qualify?* This field is required.In addition to our grants, we have interest-free loans available for grant applicants through the Hebrew Free Loan Society. Interest free loans can cover both fertility treatments, as well as, the costs associated with adoption, surrogacy, medication, donor eggs, donor sperm, and more.
Yes
No
N/A
59
Have you ever been convicted of or pleaded guilty to a felony or misdemeanor?* This field is required.
Yes
No
60
Has your partner ever been convicted of or pleaded guilty to a felony or misdemeanor?
Yes
No
61
If yes, please explain the conviction history.
62
Have you ever filed for bankruptcy?* This field is required.
Yes
No
63
Have you ever foreclosed upon a home?* This field is required.
Yes
No
64
Does anyone in your household smoke?* This field is required.
Yes
No
65
Does anyone in your household use drugs?* This field is required.
Yes
No
66
Are any family members receiving treatment for an ongoing medical or psychological condition?* This field is required.
Yes
No
67
Doctor's Letter* This field is required.Please upload a letter from your fertility doctor stating that you are in need of the treatment being sought. Note: You will not be considered without this letter.
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68
Would you be open to sharing your story anonymously to help others in similar situations?
Yes
Maybe Later
No
69
Personal Statement* This field is required.Describe your situation and why we should consider you for a grant
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70
Health Insurance Card(s) — Front and Back
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Max. file size: 10.0MB
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71
Two Reference Letters* This field is required.Please upload two reference letters attesting to your character. One letter must be from a rabbi or someone who can attest to your Jewish identity and commitment to raising a child with Jewish values.
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72
Two Most Recent Pay Stubs — Applicant* This field is required.
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73
Two Most Recent Pay Stubs — Partner
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Max. file size: 10.0MB
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74
I certify that all information in this application is true, current, and complete.* This field is required.
I certify
75
I would like to receive occasional updates from Stardust Fertility Foundation.
Yes
No
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