2024 Fertility Dreams Foundation Application
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Email *
Name of Applicant *
Name of Applicant *
Are you citizens of the United States *
Required
Age of Applicants *
Have you been accepted into the Shady Grove Shared Risk Program? At this time all recipients must be accepted into this program.
 *
Name of Shady Grove Doctor? *
Do you have any children *
Required
Have you already gone through an IVF fertility treatment? *
If yes to the above question, please advise how many
Marital Status *
Required
Annual household income *
Total out of pocket expenses needed for a fertility treatment? *
Are you and your partner willing to volunteer to support Fertility Dreams Foundation? *
If yes to the above questions, please briefly describe how you would volunteer
Are you and your partner willing to attend the annual Fertility Dreams Foundation Gala in 2024? *
Have you ever been convicted of a felony? *
If yes to the above question, please explain.
Employer of Applicants
Applicant 1: Company Name *
Applicant 1: Company Address
 *
Applicant 1: Company Phone
 *
Applicant 2: Company Name *
Applicant 2: Company Address
 *
Applicant 2: Company Phone
 *
Please share your journey and thoughts on what this grant means to you and your partner.  Please feel free to submit a video to Sarah@fertilitydreamsfoundation.com *
Consent and Signature
  1. To having first names and photographs published and released by Fertility Dreams Foundation if we are
    awarded this grant and described in that press release as recipients of the Fertility Dreams Foundation
    Family Grant.

  2. We will not receive any money directly; the grant award will be provided directly to the service providers
    (fertility clinic, adoption agency, pharmacy, or other related parties).

  3. If we are awarded a FDF Grant that the money must be used within 12 months of the grant’s
    commencement date for the purposes which it was requested, and that any unused funds will be returned to the FDF general fund.

    4. If it is found that any information contained in this application was falsified, if the instructions were not followed, or if your family, fertility, or legal status changed following the submission of this grant and the FD Foundation was not notified of such a change, the grant money, if offered, may be rescinded or forfeited depending on the specific circumstance at the discretion of the Board of Trustees,

    5. Fertility Dreams Foundation has the right to confirm that applicants are in good standing with their fertility clinic or adoption agency.

    6. The information contained in this application is truthful.
Signature and Date *
Signature and Date *
Submit
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