SIMPSON FAMILY GRANT-ORANGE COUNTY, CA

Application Deadline: August 1, 2020

Recipient announced: August 15, 2020

Questions? Email us at info@defiantlyhopeful.org

Important: 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

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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SIMPSON FAMILY GRANT / INFERTILITY GRANT AGREEMENT

1. PURPOSE The undersigned agrees that to be eligible for the Simpson Family Infertility 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 Simpson Family Grant, heretofore known as “SFG.”

We understand that all funds awarded by the SFG are non-transferable, not redeemable for cash, and are under the ultimate control of the SFG, 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 SFG, 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 SFG for payment and/or reimbursement of any kind.

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

5. CONSENT TO CONTACT We hereby give SFG 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 SFG about our treatment.

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

We further understand that once all funds are depleted from our SFG, SFG 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 SFG 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 Simpson Family 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 Simpson Family Grant through the Love Multiplies 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 Simpson Family Grant.

 

All information submitted to The Simpson Family Grant will be held in strictest confidence and viewed only by the selection committee. We thank you for your interest in The Simpson Family 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 "SIMPSON FAMILY 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 "SIMPSON FAMILY 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: If your form is missing required information you will have to enter your credit card info again to submit the form. You will not be charged unless the form is successfully submitted.
You will also need to re-select which files to upload (insurance cards, photos, personal story)

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