A – Empowering Moms: The LMC Foundation (Lesbian Moms Club)

Application for Financial Assistance

Thank you for expressing interest in the Fertility Assistance Program offered by the Lesbian Moms Club. We understand the importance of family-building and are committed to supporting individuals and couples on their journey to parenthood. To apply for our program, please complete the following application form. Applications close April 25th.

First Name

Last Name

Pronoun

Date of Birth

Address

Phone Number

Relationship Status:

Are you single or in a committed relationship? If in a relationship, please provide your partner's name and contact information.

Partners Information

Annual Household Income:

Do you have health insurance that covers fertility treatments?

Are you currently receiving any financial assistance for fertility treatments from other organizations or programs?

Yes No

Please share your story and explain why you are seeking fertility assistance.

How would receiving fertility assistance through our program impact your life and your desire to become a parent?

Do you have a support system in place to help you through the fertility treatment process and potential parenthood?

Is there any additional information you would like to provide that you believe would be helpful for us to know?

Please read and check to complete the application.

We will review all applications carefully and select recipients based on various criteria, including financial need, medical history, and personal circumstances. Please note that the Fertility Assistance Program has limited availability, and submitting an application does not guarantee acceptance into the program. All information provided will be kept confidential and used solely for the purpose of evaluating your eligibility for the program. If you have any questions or need further assistance, please do not hesitate to contact us. We are here to support you throughout this process. Thank you for considering the Fertility Assistance Program offered by the Lesbian Moms Club. We wish you the best of luck on your journey to parenthood.

Application for Financial Assistance

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