Dem Bois Inc. 2026 Gender Affirming Surgery Grant Application

1

Chosen Name* This field is required.

2

Pronouns (select all that apply)* This field is required.

He/Him/His

She/Her/Hers

They/Them/Theirs

Other

3

Race/Ethnicity (select all that apply)* This field is required.

Black/African American

Arab/Arab American

Asian

Lantine/Hispanic

Bi/Multi Racial

Indigenous/Native American

Middle Eastern/ North African

Native Hawaiian/Pacific Islander

Un-named/Unlisted Identity

4

Age* This field is required.

5

Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

6

Phone Number(Optional)

Phone Number

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E-mail* This field is required.Please double check that your email address is correct. We can't notify you if we can't reach you.

example@example.com

8

How did you hear about Dem Bois Inc.?* This field is required.

9

Tell us about your transition journey. We would love to know more about who you are as a person.* This field is required.

10

When you achieve gender affirming surgery, how will it enhance your life?* This field is required.

11

Do you currently have health insurance? If so, does your benefits cover trans related procedures?* This field is required.

12

Have you had any previous gender affirming surgery? If so, which surgeries have you had?* This field is required.

13

What gender affirming surgery are you looking to receive financial assistance for? Chest reconstruction? Phalloplasty? Etcetera? (Explain)* This field is required.

*Note; taking of hormones is not a requirement in order to identify as trans and or to be eligible for economical assistance.

14

What will be the cost of your surgery?* This field is required.

15

How much, if any, have you saved or collected so far and expect to receive towards the cost of surgery?* This field is required.

16

Do you have a support system in place to help you after surgery? (friends, family, significant other, spouse, etcetera)* This field is required.

17

Do you understand the steps that are currently required to undergo the medical process of transitioning?* This field is required.

18

Have you selected a surgeon who is knowledgeable and has experience with transition related surgeries? (limited to surgeons in the US) If so, who? Name? Address? Phone number? Website? (short answer) *Note; If selected to receive financial assistance, Dem Bois Inc. will assume the named surgeon is final. Unless you inform us otherwise* This field is required.

19

Are there any additional comments or remarks that you would like to be included with your application?(Optional)

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*Note; Please take into consideration your needs and the needs of others. If you have access to obtaining gender affirming surgery without the help and assistance of others please reframe from submitting this application. This organization was created to support those who are in need for assistance. Submitting an application without such need has the potential of taking away the means from someone who desperately needs assistance.