APPLICATION FORM

- Step 1 of 8

Personal Information

*Please note: unfortunately at this time we are unable to offer grants for egg freezing.

Please share your personal statement :

Applicant 1

(Primary Contact)

First Name *

Last Name *

Date Of Birth *

Current Age *

Phone *

Email *

Were you raised Jewish? *

Do you consider yourself Jewish now? *

Please choose one *

Relationship Status *

Highest degree earned *

Have you ever been convicted of a felony or misdemeanor? *

Applicant 2

(partner's information, if applicable)

Are you a Single Parent?

First Name *

Last Name *

Date Of Birth *

Current Age *

Phone *

Email *

Were you raised Jewish? *

Do you consider yourself Jewish now? *

Please choose one *

Relationship Status *

Highest degree earned *

Have you ever been convicted of a felony or misdemeanor? *

Have you (and your partner if relevant) participated in a genetic screening test yet? *

Household Information

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you own or rent your house?

Monthly payment/rent amount *

Number of Children from female applicant (current or previous relationships) *

If yes, how were your previous children conceived (naturally, IVF, adoption, surrogacy, etc.)? *

Are any of your family members receiving treatment for an ongoing medical or psychological condition? *

If yes, please explain

Does anyone in your household smoke? *

Does anyone in your household use drugs? *

How did you hear about Stardust? *

Stardust Staff
Google/Website
Social Media
Fertility Clinic
Gynecologist
Stardust Board Member
Others

Please Specify: *

Employment Information

Applicant 1 - Current Employer

Name of the Employer *

How long have you worked at your current job? *

Employer Address *

Address Line 1

Address Line 2

City

State

Zip Code

Employer Phone *

Position Title *

Type of Employment *

Have you ever filed for bankruptcy? *

Has any home of yours ever been foreclosed upon? *

Employment Information

Applicant 2 - Current Employer

Name of the Employer *

How long have you worked at your current job? *

Employer Address *

Address Line 1

Address Line 2

City

State

Zip Code

Employer Phone *

Position Title *

Type of Employment *

Previous Fertility Expenses

Previous Infertility Treatment & Other Extraordinary Expenses

Treatment/Expense #1 - Please explain

Treatment Date for Treatment #1

Amount For Treatment #1

Treatment/Expense #2 - Please explain

Treatment Date for Treatment #2

Amount For Treatment #2

Treatment/Expense #3 - Please explain

Treatment Date for Treatment #3

Amount For Treatment #3

Please upload Doctor's recommendation letter and any relevant documents from previous fertility treatments

Click or drag files to this area to upload. You can upload up to 5 files.

You can upload JPEG, JPG, PNG or PDF

Please upload any relevant previous fertility treatments estimates or bills

Click or drag files to this area to upload. You can upload up to 5 files.

You can upload JPEG, JPG, PNG or PDF

Please upload any documents that are related to having undergone preliminary fertility treatment such as reports, tests, and procedures or steps toward surrogacy

Click or drag files to this area to upload. You can upload up to 5 files.

You can upload JPEG, JPG, PNG or PDF

Please Describe Any Additional Infertility Treatments & Other Extraordinary Expenses

Financial Comments/Descriptions (Please include any details pertaining to the above or provide additional information you deem necessary)

Previous Fertility Expenses

Treatment Costs and Funding Request

Clinic Providing Treatment *

I'm applying for a grant for *

Physician: *

Are you a former Stardust IVF grant recipient? *

Description of Anticipated Expenses (Procedures, Labs, Meds, etc.)

Insurance Coverage

Fertility Clinic Costs *

Amount

Medications Costs *

Amount

Other Costs *

Amount

Your Costs

Fertility Clinic Costs

Medication Costs

Other Costs

Does Applicant have medical insurance?

Does Applicant 2 (Partner if relevant) have medical insurance?

Please upload the Insurance Cards

Click or drag files to this area to upload. You can upload up to 2 files.

You can upload JPEG, JPG, PNG or PDF

Please upload Letter of Recommendation

Click or drag files to this area to upload. You can upload up to 2 files.

You can upload JPEG, JPG, PNG or PDF

Additional information about costs or insurance coverage

INTEREST FREE LOANS AVAILABLE!

Interest free loans can cover both fertility treatments, as well as, the costs associated with adoption, surrogacy, medication, donor eggs, donor sperm, and more.

Please choose below if you would like more information. *

Have you applied for other Loans/Funding/Grants (Please describe): *

Stardust’s Fertility Grant expects recipients to pay a portion of the treatment cost. How do you plan to pay for your portion of the costs? *

Other: Please define *

Signatures

The information contained in this application is true, complete, and accurate to the best of applicant's and co-applicant's personal knowledge and belief. We understand that Stardust Jewish Fertility Foundation does not guarantee success in any medical procedure nor does Stardust guarantee the quality of outcomes of any medical services. Stardust reserves the right to request additional information at any time and/or to request a background check. Stardust will not consider applicants that provide false information.

Signature of Applicant 1 *

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Signature Date *

Signature of Applicant 2

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Signature Date *

APPLICATION FORM

Personal Information

Applicant 1

Applicant 2

Household Information

Employment Information

Employment Information

Previous Fertility Expenses

Previous Fertility Expenses

Description of Anticipated Expenses (Procedures, Labs, Meds, etc.)

INTEREST FREE LOANS AVAILABLE!

Signatures

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