Apply today

The application period begins at midnight EST on August 6, 2022 and runs until 11:59pm EST on October 8, 2022.

YOUR INFORMATION

First name*

Last name*

Address Line 1*

City*

State*

Postal Code*

Email*

Phone*

Your Pronouns*

Age*

I agree to terms and agreements.

INFO ABOUT YOUR SURGERY

The questions below regarding savings, health insurance coverage, or your preferred surgeon will not impact your likelihood to receive funding. We ask these questions in case we are able to connect you with other resources and opportunities. Please answer as honestly as you can.

What surgery/surgeries are you applying for assistance for?*

How much do you have saved for your surgery (in USD)*

Have you received an estimate or quote for your surgery? If yes, how much?*

Do you have health insurance? If yes, what provider do you have?*

Please list your preferred surgeon(s), if applicable.*

Would you consider a different qualified surgeon?*

DEMOGRAPHIC INFO

The demographic info collected in this section helps us identify additional grant and partnership opportunities, and better serve our applicants and community in the future. Your responses will not affect your eligibility. It is for statistical use only.

What is your ethnicity origin?*

What is your gender identity?*

Veteran/Military Status*

Do you have any long-standing illness, disability or infirmity? (Long-standing means anything that has troubled you over a period of time or that is likely to affect you over a period of time.)*

Are you currently, or have you ever experienced homelessness or housing insecurity.*

Are you currently, or have you ever experienced discrimination by your health care provider?*

SHORT ANSWER 1

Describe your current financial situation. (800 character limit)?*

This question impacts our decision-making process more than any other response. We ask this question to understand the expenses and circumstances that have created your financial need, as well as the lack of access to outside financial resources. Examples of what you can discuss here are:

Your employment situation, or if you’re unemployed·
Your housing situation, or if you’re living with housing insecurity/homelessness·
If you are the main financial provider for others, and what that looks like·
If you have other medical or financial concerns outside of your transition·
If you are a student
If you’ve experienced unique or extreme circumstances in your life that have
Impacted your savings or financial ability to afford care
Your support system for after your surgery
Any gap needs you may encounter

SHORT ANSWER 2

Describe all attempts you have made before to afford gender-affirming care, including savings, fundraising, or insurance. (800 character limit)
We ask this question to understand what steps you have taken in your health care journey and
that you fully understand the roadblocks unique to your situation and exhausted different
potential solutions to overcome them. Examples of what you can discuss here are:

Research you’ve taken towards your procedure(s), such as pre-op considerations, post-op recovery considerations, preferred surgeons.
Research or action you’ve taken regarding health insurance, such as: obtaining insurance or changing insurance providers, appealing an insurance denial, seeking CareCredit or financing
Financial decisions you’ve made to attempt to fundraise for care, such as: creating a surgery savings account, taking on an additional job, hosting a fundraiser, GoFundme, T-shirt, other organizations you have partnered with. sales etc.

SHORT ANSWER 3

Describe your support system. Tell us about the people in your life who you lean on for support. This can include but is not limited to family, chosen family, friends, neighbors, and hired personnel/staff.(800 character limit)
We ask this question to understand your living environment and support network, and understand whether your environment is stable to assist in your recovery.

SHORT ANSWER 4

Tell us something else about yourself. (800 character limit)
Each of us is a culmination of our experiences and so much more than just our trans identity.Who are you? What is important to you? What do you want to do in the future? We ask this question because we want to have a better understanding of who you are as a person.Examples of what you can discuss here are:

Your goals and dreams for the future
Activities or things you’re passionate about
Community groups or networks you may be a part of
Lived experiences that have shaped the person you are today

SUBMIT YOUR APPLICATION

By submitting you agreeing to our terms and agreements.

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