Application for Trans Health Fund

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Email *

Full Name *

What pronouns do you use?

She/Her

They/Them

He/Him

Other:

Mailing Address *

Phone Number *

Age *

Race/Ethnicity

Black

Latinx

Asian

Native/Indigenous

White

Biracial or Multiracial

Other:

What items are you looking to obtain? *

Chest Binder

Padded Bra

Breast Forms

Gaff

Medical Tape (for tucking)

Tucking Underwear

Packer Underwear

Single Prosthetic Packer

Wig

Other:

Required

Please share with us (if you are comfortable) a statement of need as to why you are seeking assistance.

How did you hear about this fund?

Please read the following carefully. By checking the boxes next to each statement, you agree to abide by these rules. *

I understand that use of these products can cause harm if not used properly. I agree to read the material provided by Shenandoah LGBTQ Center concerning safe use of these products and follow those guidelines to the best of my ability. I understand that if I have questions or need help, I can reach out to the Center for more information.

I take full responsibility for the proper use of these products and understand the potential risks they may pose. Therefore, I will not hold the Shenandoah LGBTQ Center liable in any way for any adverse effects of using these products.

I understand that I can apply only once each calendar year to this fund. An award one year does not guarantee that I will get another award the following year. I understand the Center reserves the right to grant or refuse future applications, and that their decision is in part influenced by the care I take in using the products I am granted.

Required

A copy of your responses will be emailed to the address you provided.

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