2022 Family Building Grant Application
All information applicants provide in this grant application is considered confidential and will not be shared with any agency or person outside of KCinfertility. The KCinfertility Board, along with any selection committee members we may appoint, is responsible for the review of all Family Building Grant applications and makes the decision about funding.  All complete applications are reviewed and considered anonymously with no regard for race, religion, sexuality, ethnicity, or national origin.

Timeline for 2022 Grant

July 31, 2022                                                           Completed Applications are due
September 2, 2022                                                 Grant Awards & Funding decisions announced via email
September 5, 2022                                                 Funds available for use by grant recipients
September 30, 2023                                               Full grant must have been used for fertility treatment or                                                                                                   adoption
                                                                                  (Any awarded funds unused by this date are forfeited unless an
                                                                                  exception is made by the KCinfertility Board)

Guidelines
1.   Applications must be submitted electronically via Google Forms with the separate Consent Form emailed           to mmarlow@kcinfertility.org
2.   Grant funding may be up to $5,000 per family.
3.   Grant money can only be used for services not yet received.  Funds will be paid directly to the service
       provider (fertility clinic, adoption agency, pharmacy or other related parties) and not to the family applying
       for the grant.
4.    Support is considered only for infertile couples who are legal permanent residents of the KC Metro Area.
5.    Applications must be complete to be considered. Applications missing information or attachments will not
       be reviewed and considered withdrawn.
6.    If a grant recipient becomes entitled to a refund of fees from an adoption agency, a fertility clinic, or FOR
       ANY REASON, KCinfertility must be reimbursed IN FULL before the grantee receives a portion of the refund.
7.    Families who adopt domestically may be eligible to receive a tax credit for money spent for adoption.
       Because they are not paid by tax payers themselves, expenses covered by grant funds cannot be claimed
       against tax credits.
8.    Any changes in fertility or family status; the clinic, physician, or adoption agency with whom an applicant is
       receiving treatment or services; or changes in contact information following the submission of an
       application should be reported to KCinfertility immediately. Failure to do so may result in forfeiture of the
       grant money.
9.    All applicants will be notified via email about funding decisions. Grant recipients will be required to sign an
       acknowledgement form and submit a picture to be used for future events prior to any funds paid out.
10.  Prior to review, all names will be removed from applications to keep anonymous from the selection
       committee. These will be held completely confidential and will not be shared with anyone outside of the
       selection committee.

Application Process: APPLICATIONS ARE DUE BY July 31, 2022

1.  Applications will only be accepted electronically.
2.  Incomplete applications will not be considered. A completed application includes the following:
                  - Personal Information Form (one per couple)
                  - Infertility History (one for each applicant)
                  - Personal Statement (one for each applicant)
                  - Consent Form (all to initial/sign)
3.  The Google Form Application and separate Consent Form should be completed no later than midnight, July
      31, 2022. Consent Form should be emailed to mmarlow@kcinfertility.org
4.  You will receive an email confirmation your application has been received. If you do NOT receive
      confirmation, please follow up by contacting Melissa Marlow, KCinfertility Treasurer and Grant Manager at
      mmarlow@kcinfertility.org

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Email *
PERSONAL INFORMATION
(This section will be separated from the rest of your application to preserve anonymity.)
APPLICANT #1
Name (Last, First) *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Email Address *
Home Street Address *
City, State, Zip Code *
Phone number *
Current Job Title *
Employer's Name *
Length of Employment *
Do you currently have any children? *
If yes, how many? Ages?
Have you ever been arrested for Misdemeanor? (If "yes" please explain in personal statement) *
Have you ever been arrested for Felony? (If "yes" please explain in personal statement) *
Are you a legal and permanent US Resident *
If no, explain:
APPLICANT #2
Name (Last, First) *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Email Address *
Home Street Address *
City, State, Zip Code *
Phone number *
Current Job Title *
Employer's Name *
Length of Employment *
Do you currently have any children? *
If yes, how many? Ages?
Have you ever been arrested for Misdemeanor? (If "yes" please explain in personal statement) *
Have you ever been arrested for Felony? (If "yes" please explain in personal statement) *
Are you a legal and permanent US Resident *
If no, explain:
APPLIES TO BOTH APPLICANTS
Relationship with Partner: *
Length of relationship with partner *
Additional personal information we may need to know:
How long have you been involved with KCinfertility?
Have you attended any of the following with KCinfertility?
Please check all that apply
If Other, please explain
INFERTILITY HISTORY APPLICANT #1
Length of time currently attempting pregnancy/adoption: *
Cause of infertility, if known:
History of pregnancies (number, year, outcome):
Please list previous infertility treatments or adoption processes undertaken (dates, types, outcomes):
Please list estimated infertility costs paid out of pocket to date: *
Break out into three categories: Fertility Treatments/Expenses, Adoption Expenses and Total Expenses
Do you have insurance sponsored support that will assist with the costs associated with fertility treatment/adoption?
Clear selection
If you answered "yes, but incomplete coverage" please describe
If awarded, how do you plan to use the Grant Funds?
(check the appropriate):
If you checked "Other" in the previous question, please explain
Are you currently working with with a fertility clinic or adoption agency?
Clear selection
If yes, who is the provider?
If applying for Adoption Assistance, have you already completed a Home Study?
Clear selection
INFERTILITY HISTORY APPLICANT #2
Length of time currently attempting pregnancy/adoption: *
Cause of infertility, if known:
History of pregnancies (number, year, outcome):
Please list previous infertility treatments or adoption processes undertaken (dates, types, outcomes):
Please list estimated infertility costs paid out of pocket to date: *
Break out into three categories: Fertility Treatments/Expenses, Adoption Expenses and Total Expenses
Do you have insurance sponsored support that will assist with the costs associated with fertility treatment/adoption? *
If you answered "yes, but incomplete coverage" please describe
If awarded, how do you plan to use the Grant Funds? *
(check the appropriate):
Required
If you checked "Other" in the previous question, please explain
Are you currently working with with a fertility clinic or adoption agency?
Clear selection
If yes, who is the provider?
If applying for Adoption Assistance, have you already completed a Home Study?
Clear selection
PERSONAL STATEMENT                                                                                                              
Each applicant should submit a personal statement, written independently. Use  this statement to tell us your story, the impact receiving the grant funds might have for you, and anything else you'd like us to know about your infertility experience. DO NOT use names in your personal statement. Applications are reviewed anonymously. We recommend you use 'she', 'he', 'wife', 'husband', 'partner', etc. in replace of names.
Applicant #1
Applicant #2
Submit
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