TrailblazeHer Fertility Grant Application
Complete this form to request support for fertility preservation or treatment—share only what’s necessary to confirm eligibility, financial need, and how you’ll use the funds.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City/State
*
Fertility Journey
Current fertility situation
*
I recently completed fertility treatment or preservation
I am currently undergoing fertility treatment or preservation
I have a treatment or preservation cycle scheduled
I am planning to begin treatment or preservation soon
Other
Type of fertility care pursued or recently completed
*
Fertility testing/evaluation
Egg retrieval
Egg freezing
Embryo freezing
IUI
IVF
Embryo transfer/implantation
Fertility medications
Fertility preservation
Other
Treatment start, completion, or expected start date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Describe where you are in your fertility journey and what process you are requesting assistance for (no diagnosis or detailed medical history needed)
*
Financial Need
Please describe the financial circumstances that make fertility treatment or preservation difficult to afford
*
Approximate annual household income
*
Under $50,000
$50,000–$74,999
$75,000–$99,999
$100,000–$149,999
$150,000–$199,999
$200,000 or more
Prefer to explain
Is any portion of fertility-related care covered by insurance?
*
Yes
No
Unsure
If known, what portion of care is covered by insurance?
Are you receiving financial assistance from another source?
*
Insurance
Employer fertility benefit
Fertility clinic assistance
Other grant
Family
Financing/payment plan
Other
None
Estimated amount you expect to pay yourself for fertility-related expenses
*
Request for Funds
What will the TrailblazeHer grant be used for?
*
Fertility consultation/evaluation
Fertility medications
Egg retrieval
Egg freezing
Embryo freezing
IUI
IVF
Embryo transfer/implantation
Laboratory/reproductive services
Other fertility-related treatment
Other
How will you use the grant?
*
Expense breakdown
*
Your Story
If you’re comfortable, please share why this grant would be meaningful to you.
What would this financial assistance make possible for you?
*
Certification
I certify that the information provided is true and accurate
*
Yes
I understand TrailblazeHer may request reasonable documentation
*
Yes
I understand that submission does not guarantee an award
*
Yes
Applicant name
*
First Name
Middle Name
Last Name
Submit Application
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