Sparkles Gardens of Life 2022 Grant Application

  • Sparkles Gardens of Life 2022 Grant Application

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

  • 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

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • PERSONAL INFORMATION

  • Date of Birth
     - -
  • Gender
  • Marital Status
  • Have you undergone In Vitro Fertilization Treatment before?
  • Does your insurance cover In Vitro Fertilization treatment?
  • Do you currently have any children?

  • GIVING BACK

  • Are you currently involved with any philanthropic or community organizations?
  • As a commitment after receiving the grant, are you available to attend the ANNUAL EVENTS
  • Are you willing to volunteer at a Sparkles of Life fundraiser or advocacy event?

  • MEDICAL HISTORY FOR WOMEN

  • Gynecological History

  • Obstetrical History

  • Result (Check all that apply)
  • Result (Check all that apply)
  • Result (Check all that apply)
  • Result (Check all that apply)
  • Result (Check all that apply)

  • Previous Infertility Testing

  • Do you have fibroids?
  • Do you have endometriosis?

  • Previous Fertility Treatments

  • Do you smoke?
  • Have you used marijuana or other illegal drugs?

  • MEDICAL HISTORY FOR MEN

  • Have you had any urological problems?
  • Have you seen a urologist?
  • Have you ever fathered a pregnancy?
  • Was the child carried to full term?
  • Have you bene told that you have male infertility?

  • Sperm Analysis

  • Have you ever been treated for cancer?
  • Do you smoke?
  • Have you used marijuana or other illegal drugs?

  • 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.)

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