Gift of Hope Online Application

Gift of Hope IVF Grant Application

BEFORE YOU BEGIN THIS ONLINE APPLICATION:

Before you begin this online application, please make sure you meet the eligibility requirements and have all the required supporting information ready to upload. This application cannot be saved to finish at a later date. ALTERNATIVELY, you can download an application and instructions to complete and mail (or hand deliver) along with required supporting documents to: Fertility Answers, 206 E. Farrel Rd, Lafayette, LA 70508. Application must be submitted by April 29, 2022. Any application received past this date will not be considered.

Eligibility Requirements

Earn less than $100,000 per year (adjusted gross income) – copy of federal tax return required

Have no or limited insurance coverage for infertility and IVF – copy of insurance cards required

Are residents of Louisiana

Have a documented medical need for in vitro fertilization – doctor’s referral is required

Have insurance coverage for prenatal care

SUPPORTING DOCUMENTS: In addition to completing the information below about applicant and partner (if applicable), you will need to also:

Upload your personal story

Upload letter from referring physician and any pertinent medical records (if not a Fertility Answers patient)

Upload 2021 federal income tax data

Upload copies of health insurance cards

APPLICANT INFORMATION

Applicant First Name(Required)

Applicant Last Name

Applicant Date of Birth(Required)

Applicant Age(Required)

Applicant Marital Status(Required)

Email(Required)

Phone(Required)

Preferred Fertility Answers Clinic(Required)

Lafayette

Baton Rouge

Applicant Address(Required)

Street Address Address Line 2 City State ZIP Code

Any children?(Required)

Yes

If yes, how many children?

Any stepchildren?(Required)

Yes

If yes, how many stepchildren?

Applicant Occupation(Required)

Applicant Employer(Required)

APPLICANT INFERTILITY MEDICAL HISTORY

Current Fertility Specialist or OB-Gyn(Required)

City/State of Fertility Specialist

City State

Have you ever been pregnant?(Required)

Yes

If yes, how many times?

If yes, how many live births?

If yes, how many losses?

Brief infertility summary(Required)

Have you ever had an IVF procedure?(Required)

Yes

If yes, how many?

If yes, which physicians/clinics?

If applicant over 35 years of age, results of most recent FSH test

If applicant over 35, results of most recent AMH test

Do you have any frozen embryos?(Required)

Yes

If yes, how many embryos and where are they stored?

Do you smoke?(Required)

Yes

If yes, how much do you smoke?

Height(Required)

Weight(Required)

Any other medical issues?(Required)

PARTNER INFORMATION

Do you have a partner?(Required)

Yes

Partner Full Name(Required)

Partner Date of Birth(Required)

Partner Age(Required)

Please enter a number from 1 to 99.

Partner Address (if different from applicant)

Street Address Address Line 2 City State ZIP Code

Partner any children?(Required)

Yes

If yes, how many children?

Partner any stepchildren?(Required)

Yes

If yes, how many stepchildren?

Partner Occupation(Required)

Partner Employer(Required)

REQUIRED DOCUMENTS UPLOAD

YOUR STORY: Upload your personal story explaining the compelling nature of your circumstances, your struggles with infertility, and why you feel you are deserving of the Gift of Hope. Photos and videos can also be uploaded to tell or support your story. Any photos or video submissions must be less than 50MB.

Drop files here or

Accepted file types: doc, jpg, png, pdf, mp4, mov, Max. file size: 50 MB.

AND/OR, provide a URL link to your story/video here:

Additional URL link (if needed):

Referral letter from current physician (this is required if you are not currently a Fertility Answers patient)

Accepted file types: doc, jpg, png, pdf, Max. file size: 50 MB.

Upload any pertinent medical records that will help us to better evaluate your need for the Gift of Hope grant

Drop files here or

Max. file size: 50 MB.

Upload 2021 Federal Tax Return and any supporting documents(Required)

Drop files here or

Max. file size: 50 MB.

Upload scanned 2021 Federal tax return(s). Please provide a copy of IRS form 1040, 1040A, 1040ES or 1040EZ - US Individual Income Tax Return of your 2020 Federal Income tax return (both returns if partners file separately). If you and/or your partner are self-employed, please include a letter describing your business, incorporation status and other details pertinent to your financial status.

Upload scans of health insurance cards, front and back, for both partners(Required)

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 50 MB.

APPLICANT CONSENT

Applicant Consent(Required)

I/We agree

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.

Consent(Required)

I/We agree

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.

I/We agree

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.