Apply For Assistance

Hasidah’s Summer 2022 Grant Cycle is Now Open.

Completed applications must be submitted by 1:00 pm PST, June 10, 2022.

Your fertility journey is very important and we understand that completing this application is yet another task you did not plan on the road to parenthood. If you have not already, please read our application process and guidelines overview.  If you have any other questions be sure to check out our financial assistance FAQ page. On the bottom of that page you will find links to sample application files to use to prepare your application.

Now that you have read the fine print, please take the time to prepare so you can carefully and completely answer all questions and provide all information. Hasidah has a very limited staff and cannot edit or correct applications. You will receive confirmation that your application was received. Applications that are incomplete or incorrectly completed may not be considered.

Check List for Applying

STOP.  Before beginning the application form below you will need to compile several documents to attach to this application form.  Use the checklist below to ensure that you have all the documents/information you will need to attach before starting to complete the form:

□ A personal statement – read the instructions and take time to write this thoughtfully!
□ Reference letter(s)
□ The last two IRS returns for both applicants (and/or joint filing)
□ The two most recent pay stubs for both applicants
□ A copy of both sides of your insurance cards (both applicants if different)
□ A COMPLETED Financial Worksheet (Do not make a PDF file. Keep as .xls)
□ A Medical Referral Form that is COMPLETED ENTIRELY by the doctor who will be providing the IVF for confirmation and completion. Leave nothing blank – put in N/A or 0. Please make sure this is legible and  provides clear explanations.
□ A copy of your Medical Release Form. This is in case any clarification is needed about your medical form, for billing information, and in order to make payment if you receive a grant. Do NOT send us your medical record files.
□ Please note there is a $50 application fee.

You may download a copy of the Authorization, Informed Consent and Release form for your records if you choose.

You can also look at a previous application sample to get an idea of the information requested on the on-line application (this is NOT the actual application and questions may vary).

All applications and parts of applications become the property of Hasidah.
Hasidah is a nonprofit, charitable, tax-exempt organization under section 501(c)(3) of the Internal Revenue Service Code.