Name
*
Applicant 1 (primary contact)
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Current Age
*
Email
*
Phone Number
*
(###)
###
####
Were you raised Jewish
*
Do you consider yourself Jewish now?
*
Jewish affiliation
*
Orthodox
Conservative
Reform
Reconstructionist
Unaffiliated
Other
Do not identify as Jewish
Not Jewish
Highest degree earned
*
High school
Associate
Bachelor
Graduate
Post grad
Have you ever been convicted of or pleaded guilty to a felony or misdemeanor?
*
Name
Applicant 2 (partner's information, if applicable)
First Name
Last Name
Date of Birth
Applicant 2 (partner's information, if applicable)
MM
DD
YYYY
Phone Number
Applicant 2 (partner's information, if applicable)
(###)
###
####
Were you raised Jewish
Applicant 2 (partner's information, if applicable)
Do you consider yourself Jewish now?
Applicant 2 (partner's information, if applicable)
Have you ever been convicted of or pleaded guilty to a felony or misdemeanor?
Applicant 2 (partner's information, if applicable)
Have you (and your partner if relevant) participated in a genetic screening test yet?
*
Current Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home
*
Own
Rent
How many children do applicants have (from current or previous relationships)?
*
Select the total number of children between both partners (if applicable)
If you have children, how were they 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
Friends/family
Other
Applicant 1: Are you employed?
*
If yes, what is your current job?
How long have you worked at your current job?
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Have you ever filed for bankruptcy?
*
Have you ever foreclosed upon a home?
*
Applicant 2: Are you employed?
*
If yes, what is your current job?
How long have you worked at your current job?
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please list any fertility treatments you have undergone and what year you went through them (put N/A if you have not yet undergone any treatments)
*
What clinic is providing your treatment, and what doctor are you seeing?
*
I'm applying for a grant for
*
Intrauterine insemination
A full IVF cycle (egg retrieval and embryo transfer)
A FET (frozen embryo transfer only)
Other (provide explanation in next question)
If you answered "other" to the previous question, please explain here
Are you a former Stardust IVF grant recipient?
*
Yes
No
Have you previously applied for a Stardust grant?
*
Yes
No
Estimated financial costs needed
*
Please provide a breakdown of your estimated financial needs (i.e., costs needed to be paid to fertility clinics, agencies, etc. to help you on your journey)
Does either applicant have medical insurance?
*
Yes
No
Has applicant or partner maxed out your fertility coverage from insurance?
*
Yes
No
If no, how much insurance coverage remains?
Have you received other grants for past fertility treatments?
*
Yes
No
If yes, please list each grant you have received, including the organization and year
Stardust cannot guarantee that it can cover all of an Applicant’s treatment costs. If you are awarded a partial grant, how do you plan on funding the remainder of the costs?
*
In addition to our grants, we have interest-free loans available for grant applicants through the Hebrew Free Loan Society. Interest free loans can cover both fertility treatments, as well as, the costs associated with adoption, surrogacy, medication, donor eggs, donor sperm, and more. Would you be interested in a loan if you qualify?
Yes
No
I'd like more information
N/A
Have you applied for other Loans/Funding/Grants for fertility? Please describe.
*
Complete application
*
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.
