DEFIANTLY HOPEFUL GRANT

Application Deadline: November 4th, 2023

Recipient(s) announced: December 2023

Questions? Email us at info@defiantlyhopeful.org

1) Before your start filling out the form please review the entire form and make sure you have all necessary information and documents. (personal story, family photo, medical evaluation, etc.)
Review the Grant Checklist here
2) If the form doesn't pass validation you will need to upload the files again to the form.
3) You can't save the form to complete later. It must be filled out completely and submitted.

PERSONAL INFORMATION

Please tell us your name.
Name of Partner
Home Address
Applicant DOB
Partner DOB
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Home Address
A personal story (maximum 1500 words)

Do NOT document your fertility history here. We want to know who you are- hobbies, profession, family history, why you would be a worthy candidate. You may include a photo but no more than 2 please.

Family Photo (Maximum of 2 photos)

IVF TREATMENT INFO


PLANNED DATE OF IVF CYCLE

IF USING DONOR OR GESTATIONAL CARRIER

TREATMENT COSTS

EMPLOYMENT HISTORY OF APPLICANT

(PLEASE INCLUDE EMPLOYMENT FOR LAST 3 YEARS)

EMPLOYMENT HISTORY OF PARTNER

(PLEASE INCLUDE EMPLOYMENT FOR LAST 3 YEARS)

EDUCATION


CRIMINAL BACKGROUND

*IF YOU ARE SELECTED AS THE WINNER- YOU WILL HAVE A FULL BACKGROUND CHECK AND GRANT MONEY WILL ONLY BE DISTRBUTED DIRECTLY TO YOUR PHYSICIAN’S OFFICE AFTER YOU AND YOUR PARTNER HAVE BEEN CLEARED. IF YOU DO NOT PASS, THE NEXT FINALIST WILL BE SCREENED.

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HEALTH INSURANCE INFORMATION

Please upload a copy of your and your partner’s insurance card.
Yu must upload your "GRANT MEDICAL EVALUATION"
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MEDICAL HISTORY

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FINANCIAL INFORMATION

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GYNECOLOGICAL MEDICAL HISTORY

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FERTILITY MEDICAL HISTORY

List all procedures you have had including medications used, follicles produced, eggs retrieved, embryos created, number of blastocysts and if you have any embryos frozen and if they have been genetically tested.

Please upload your GRANT MEDICAL EVALUATION that has filled out by your Physician Click here to download form

Yu must upload your "GRANT MEDICAL EVALUATION"
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DEFIANTLY HOPEFUL GRANT / INFERTILITY GRANT AGREEMENT

1. PURPOSE The undersigned agrees that to be eligible for the Defiantly Hopeful Grant, my partner and I meet the American Society for Reproductive Medicine’s definition of infertility, and that any grant awarded is done so for the sole purpose of obtaining assistance with fertility treatment.

2. DISTRIBUTION OF FUNDS We understand that signing this consent does not guarantee that we will be awarded a grant from The Defiantly Hopeful Grant, heretofore known as “DHG.”

We understand that all funds awarded by the DHG are non-transferable, not redeemable for cash, and are under the ultimate control of the DHG, and all final decisions regarding distribution of funds is left solely in the Board of Director’s discretion. A copy of our award letter will go directly to our board of directors informing them of the grant award. All funds awarded will go directly to the physician’s office and will be used for the primary benefit of infertility treatment and not to be used for the primary benefit of the family to relieve a personal financial burden.

Acceptable expenses for grant disbursements include, but are not limited to: • Prescription Costs • Lab Work Expenses • Medical Expenses for Fertility Treatments • Pre-Approved Gestational carrier expenses •Pre-approved Egg donor expenses

Expenses that are not acceptable for grant disbursements include, but are not limited to: • Personal mileage reimbursement • Personal meal expenses • Personal home modifications or improvements to accommodate a child

3. USE OF FUNDS FOR INFERTILITY EXPENSES We agree that if we decide not to go through with treatment plan to immediately contact DHG, and any funds that have not been disbursed for treatment expenses will be used to further assist other families with the cost of treatment.

We further agree to submit proper documentation as requested by DHG for payment and/or reimbursement of any kind.

4. PERMISSION TO USE STORY & PICS We give DHG permission to use our family’s story and any pictures we share to help promote the ministry of DHG on any social and news media platforms of DHG or Defiantly Hopeful choosing.

5. CONSENT TO CONTACT We hereby give DHG consent to contact our fertility doctor/clinic, and any other person or institution named on the attached form, and authorize such person(s) and/or institution(s) to verify information for DHG about our treatment.

6. WAIVER OF LIABILITY We understand that DHG is not responsible if our treatment is not successful, and hereby release DHG from any and all financial liability resulting from a failed treatment.

We further understand that once all funds are depleted from our DHG, DHG is not responsible for any subsequent treatment expenses.

7. REFUND POLICY We understand there is no refund of application fee once submitted. We understand the application fee will be used to offset the cost of administration fees and cover the cost of the background check for the selected recipient.

8. COVERAGE DATES OF THE DHG We understand that the coverage dates of the Grant begin the day the funds are distributed to the physician’s office and must be used within 365 days. We further understand that the Grant cannot be used for expenses incurred or services provided outside of the coverage dates.

12. ACKNOWLEDGMENT We acknowledge that we have thoroughly read this waiver/consent, and fully understand and voluntarily agree to the terms set forth. We sign voluntarily on our own free act, and no oral representations, statements, or inducements apart from the foregoing in this written agreement have been made.

RELEASE AGREEMENT

The Applicant hereby assigns and grants the Organization and its legal representatives the irrevocable and unrestricted right to use excerpts in whole or in part from the Applicant’s personal statement for editorial, trade, advertising, or any other purposes and in any manner and medium; to alter the same without restrictions; and to copyright the same. The Applicant hereby releases the organization and its legal representatives and assigns from all claims and liability relating to said excerpts. Any person mentioned in the Applicant’s personal statement shall be deemed to have consented to the use of their name, image, or likeness by Applicant and/or Organization and Applicant shall defend and indemnify the Organization from and against any claims that any of the Applicant’s friends, family, or other persons mentioned in the personal statement may assert against the Organization arising from, or related to, the use of any name, Image, or likeness of Applicant’s friend, family, or other person mentioned in the personal statement by Organization. Surnames will NOT be used so as to protect the identification of any of the above.

I give my permission for The Defiantly Hopeful Grant to contact my physician and/or clinic’s business manager.

AUTHORIZATION AGREEMENT

By signing, I authorize my clinic to disclose certain health information about me to the Defiantly Hopeful Grant through the Defiantly Hopeful Organization.

This authorization form permits the above mentioned clinic to disclose health information about me and my partner for the purpose of applying for a grant through The Defiantly Hopeful Grant. 

All information submitted to The Defiantly Hopeful Grant will be held in strictest confidence and viewed only by the selection committee. We thank you for your interest in The Defiantly Hopeful Grant and wish each and every one of you the best in your attempt to build your family.

 

Applicant Agreement
By signing below the "Applicant" agrees to the following

I agree to the "DEFIANTLY HOPEFUL GRANT / INFERTILITY GRANT AGREEMENT"
I agree to the "RELEASE AGREEMENT"
I agree to the "AUTHORIZATION AGREEMENT"

You must sign to submit application

 

Partner Agreement
By signing below the "Partner" agrees to the following

I agree to the "DEFIANTLY HOPEFUL GRANT / INFERTILITY GRANT AGREEMENT"
I agree to the "RELEASE AGREEMENT"
I agree to the "AUTHORIZATION AGREEMENT"

You must sign to submit application

 

Application Fee is $25

Once you click the submit button you will be required to pay with a credit card to fully submit this application

Important:

  1. It's a good idea to save all the text you wrote into the form on your computer as a backup before going to the next payment step.
  2. You may need to re-select which files to upload if the form doesn't validate (insurance cards, photos, personal story)
  3. Please check that all fields are filled and files uploaded before proceeding.
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