Sparkles Gardens of Life 2022 Grant Application

Sparkles Gardens of Life 2022 Grant Application
Date

MonthDayYear
Date
How did you hear about Sparkles' Garden of Life Grant?

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Thank you for your interest in the Sparkles' Garden of Life Grant. Please remember that all application materials must be submitted to info@sparklesoflife.org no later than January 10, 2023. All application materials, including the W2 form(s) and PayPal receipt, must be sent together in one email submission.

Application materials will be kept confidential and reviewed only by the Sparkles' Garden of Life Selection Committee. The Garden of Life Grant has a cash value of $3,000 to be used for In Vitro Fertilization treatment. The grant pays the treatment exclusively and does not cover associated medical costs (i.e. medications, post-treatment medical procedures, etc.). By submitting application materials to info@sparklesoflife.org, you are agreeing to find/provide the additional funding needed to cover the remaining cost of IVF treatment, if awarded the grant. Please note that submitting false information, or omitting critical information, will result in disqualification from the grant program.
CONTACT INFORMATION
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Email
example@example.com
PERSONAL INFORMATION
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Estimated Household Income:
Marital Status

SingleMarriedDivorcedWidowed
If married, how long? (Years)
Spouse's Name
Spouse's Occupation
How long have you lived in the Houston area? (years)
Current Job Title
Address of Employment
Name of Supervisor
Supervisor's Phone Number
Supervisor's Email
Name & Phone Number of Your Fertility Clinic and/or Doctor
Have you undergone In Vitro Fertilization Treatment before?

YesNo
Why are you applying for the Sparkles' Garden of Life Grant?
Does your insurance cover In Vitro Fertilization treatment?

YesNo
Do you currently have any children?

YesNo
If Yes, how many?
GIVING BACK
Are you currently involved with any philanthropic or community organizations?

YesNo
If yes, please elaborate
As a commitment after receiving the grant, are you available to attend the ANNUAL EVENTS

YesNo
If no, please explain why not.
Are you willing to volunteer at a Sparkles of Life fundraiser or advocacy event?

YesNo
If yes, explain how you would like to contribute.
MEDICAL HISTORY FOR WOMEN
Height
Weight
Body Mass Index
Length of Time Currently Attempting Pregnancy
Gynecological History
Age of first menstrual cycle
Average length of menstrual cycle
History of surgery
History of Endometriosis
History of Pelvic Infections
Obstetrical History
Pregnancy #1 (Year)
Result (Check all that apply)

Full TermPretermMiscarriageTerminations
Pregnancy #2 (Year)
Result (Check all that apply)

Full TermPretermMicarriageTerminations
Pregnancy #3
Result (Check all that apply)

Full TermPretermMiscarriageTerminations
Pregnancy #4
Result (Check all that apply)

Full TermPretermMiscarriageTerminations
Pregnancy #5
Result (Check all that apply)

Full TermPretermMiscarriageTerminations
Previous Infertility Testing
HSG Results
Laparoscopy
Hysteroscopy
Other gynecological surgery
Ultrasound results
Do you have fibroids?

YesNo
Do you have endometriosis?

YesNo
If yes, which stage?
Previous Fertility Treatments
Procedure #1 Date
Out of Pocket Cost to You
Amount Covered by Insurance
Procedure #2 Date
Out of Pocket Cost to You
Amount Covered by Insurance
Procedure #3 Date
Out of Pocket Cost to You
Amount Covered by Insurance
Procedure #4 Date
Out of Pocket Cost to You
Amount Covered by Insurance
Procedure $5 Date
Out of Pocket Cost to You
Amount Covered by Insurance
Medical Problems
Surgical History
Do you smoke?

YesNo
What prescriptions/over the counter drugs do you take?
Have you used marijuana or other illegal drugs?

YesNo
If yes, please detail which drugs and your frequency of use
Significant Family Medical History
Please detail any other important health and/or medical information you think the selection committee should know
MEDICAL HISTORY FOR MEN
Height
Weight
Body Mass Index
Length of time of trying to conceive
Have you had any significant medical problems?
Please detail your surgical history
Have you had any urological problems?

YesNo
Have you seen a urologist?

YesNo
If yes, please write the urologist's name and phone number below
Have you ever fathered a pregnancy?

YesNo
If yes, when?
Was the child carried to full term?

YesNo
Have you bene told that you have male infertility?

YesNo
If yes, what is/was the issue?
Sperm Analysis
Date
Count
Motility
Morphology
Have you ever been treated for cancer?

YesNo
If yes, what medications/treatments?
Medical Problems
Surgical History
Do you smoke?

YesNo
What prescription/over the counter drugs to you take?
Have you used marijuana or other illegal drugs?

YesNo
Significant Family Medical History
Please detail any other important health and/or medical information you think the selection committee should know
FILE UPLOADS

Please upload supporting documentation here
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UPLOAD PAYMENT RECEIPT HERE
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DISCLAIMER
By signing below, I authorize Sparkles of Life, Inc. and the Sparkles' Garden of Life Selection Committee to obtain information - written, oral, or other - from my physician and any law enforcement agency, consumer reporting agency, or other persons with knowledge of such information, bearing on my character, general reputation, personal characteristics, mode of living, criminal background and driving record. Sparkles of Life reserves the right to conduct this investigation at any time.

I am aware that my name, address, telephone number, and e-mail address will be distributed to the Sparkles of Life board after the grant has been awarded. I understand that only my contact information will be available to board members, and all other information contained in the application materials will remain confidential, reviewed only by members of the selection committee.

The information I have given is correct and you may verify the information listed if necessary. I understand that selection is at the discretion of the Sparkles' Garden of Life Selection Committee and will not seek compensation of any sort in regard to the decision of the final awardees or the selection process/criterion.

(Electronic signatures are acceptable.)
Applicant Signature

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Date
Spouse's Signature

Clear
Date
Should be Empty:

Sparkles Gardens of Life 2022 Grant Application

CONTACT INFORMATION

PERSONAL INFORMATION

GIVING BACK

MEDICAL HISTORY FOR WOMEN

Gynecological History

Obstetrical History

Previous Infertility Testing

Previous Fertility Treatments

MEDICAL HISTORY FOR MEN

Sperm Analysis

FILE UPLOADS

UPLOAD PAYMENT RECEIPT HERE

DISCLAIMER