I/We declare my/our application to be the full truth to the best of my/our knowledge. I/we have read through the application instructions, eligibility requirements and frequently asked questions. I/we understand what is covered and not covered by the Gift of Hope Grant, and what services I/we may still need to pay for. This includes a $3,000 cap on medications required for the IVF cycle. I/we understand that I/we are financially responsible for medication costs over $3,000.

I/we understand that selected applicant will be required to sign additional Medical Consent forms before infertility treatment cycle commences. I/we understand that I/we may be declined the award if I/we fail to meet prescreening needs for in vitro fertilization. In this case, another couple may be selected to receive the GIFT of HOPE.

Rights Granted to GIFT of HOPE: The undersigned, an applicant to participate in GIFT of HOPE, an IVF grant program sponsored by Fertility Answers LLC, grants and conveys to GIFT of HOPE the exclusive rights to develop and tell the applicant’s Story related to the applicant’s efforts to build a family, including but not limited to, information regarding the applicant and partner, the applicant’s immediate family members, the applicant’s medical and financial struggles related to pregnancy, pregnancy loss, infertility, fertility treatment, etc. (known in this agreement and release collectively as your “Story”). Applicant grants GIFT of HOPE the exclusive right to share your Story in any and all media, now and hereafter developed, including but not limited to print media including books and magazines, and electronic media including all donors’ websites and social media platforms. Applicant agrees to be truthful with respect to all information provided to GIFT of HOPE for inclusion in applicant’s Story. Applicant understands that providing incomplete, inaccurate or false information will cause significant harm to GIFT of HOPE and agrees to indemnify and hold GIFT of HOPE and its respective donor organizations harmless against any claim, demand, or recovery brought against GIFT of HOPE as publisher of the applicant’s Story with respect to any information applicant provides that is not complete, correct, accurate and truthful. Upon selection for participation in GIFT of HOPE, applicant agrees to provide GIFT of HOPE and/or its agents with photographs of applicant, applicant’s partner and immediate family members and additional information to facilitate the telling of applicant’s Story as requested by GIFT of HOPE. Applicant agrees to allow GIFT of HOPE and/or its representatives or agents to attend, photograph, videotape and otherwise record for purposes of telling applicant’s Story, applicant’s medical appointments and other events related to applicant’s efforts to build a family. Applicant agrees and understands that she/he shall receive only the donated medical services included in the program as consideration for granting these rights to GIFT of HOPE and its respective donor organizations and shall receive no other consideration or compensation for granting these rights. Applicant hereby waives claim to any royalties, fees or other compensation GIFT of HOPE may receive related to publishing or other telling of applicant’s Story. THE UNDERSIGNED APPLICANT AND PARTNER HAVE READ AND UNDERSTAND THE RIGHTS GRANTED TO GIFT OF HOPE AND ITS RESPECTIVE DONOR ORGANIZATIONS IN THIS COPYRIGHT AND MEDIA RELEASE AND VOLUNTARILY GRANT THE RIGHTS DETAILED IN THIS RELEASE TO GIFT OF HOPE IN CONSIDERATION FOR THE OPPORTUNITY TO APPLY TO PARTICIPATE IN THE GIFT OF HOPE PROGRAM.