Section 1. General information of person with Polycystic Kidney Disease:

First Name

Last Name

Email *

Phone *

Message & data rates may apply. By providing my phone number I agree to receive communications from pkDO and agree to the terms & conditions.

Street Address *

City *

State *

Zip Code *

Date of birth *

Gender *

Number of dependents listed on your most recent tax return *

Health insurance provider *

Does your insurance cover any portion of IVF (must be checked with your insurer)? *

Did you and your partner file taxes jointly or separately? *

Jointly

Separately

Please provide your adjusted gross income from Line 11 of the first page of your federal tax returns:

Amount For 2021 *

Amount For 2022 *

Amount For 2023 *

Current employer name *

Current Employer Address *

Years with this employer *

Current position / job title *

Current salary *

Have you ever been convicted of a felony? *

Yes

If you have been convicted of a felony, please explain

Section 2. General information of partner:

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Email *

Phone *

Date of birth *

Gender *

Are you a carrier of polycystic kidney disease *

Yes

Unknown

Relationship to applicant #1 *

Number of dependents listed on your most recent tax return and their dates of birth *

Number of household members included on your tax return and relation to you *

Health insurance provider *

Please provide your adjusted gross income from Line 11 of the first page of your federal tax returns (Disregard if filed jointly):

Amount For 2021 *

Amount For 2022 *

Amount For 2023 *

Current employer name *

Current Employer Address *

Years with this employer *

Current position / job title *

Current salary *

Have you ever been convicted of a felony? *

Yes

If you have been convicted of a felony, please explain

Section 3. Government Assistance

Are you, or is anyone in your household, receiving government assistance of any type? *

Yes

If yes, please identify the government assistance programs

Identify whether you are, or anyone in your household is, receiving assistance from any of the following government programs:

Supplemental Security Income (SSI) *

Yes

Medicaid *

Yes

Social Security Disability Insurance (SSDI) *

Yes

Medicare low-income plan *

Yes

HUD housing *

Yes

TANF (Temporary Assistance for Needy Families) *

Yes

Food Stamps *

Yes

Section 4. Partner Fertility Facility Preference

Click the links below to determine your top two Partner Fertility Center Facility location preferences and distance from your residence:

Fertility Center Name & Location

(if unsure leave blank)

Distance From Your Residence

(if unsure leave blank)

Fertility Center Name & Location

(if unsure leave blank)

Distance From Your Residence

(if unsure leave blank)

Section 5. Additional application information.

Photocopy of both applicants’ insurance cards, front and back

Video to introduce yourselves and share your reasons for applying to the pkDO IVF Grant (4 minute limit).

Written Essay (optional and 400-word limit - e.g., anything else you would like us to know about you).

To be provided after provisional grant award:

Copies of your three most recently filed tax returns (IRS Form 1040) to be provided within two weeks after notification of winning award.
Signed background check authorization to be provided within 2 weeks after notification of winning award.
Signed Release and Waiver *to be provided within two weeks of winning award.
Viability Assessment Letter from Partner Fertility Facility

Section 6. Authorization:

By checking this box, I hereby authorize the Polycystic Kidney Disease Outreach Foundation, LTD, (pkDO) and Partner Fertility Clinic to verify my insurance coverage. *

I Agree (Applicant One)

I Agree (Applicant Two)

By checking this box, and in the event I receive a pkDO IVF grant, I hereby authorize pkDO and Partner Fertility Clinic to use any photographs, audio recording, video recordings, and writings related to participation in the pkDO Grant to be used for educational, promotional, or fundraising purposes. *

I Agree (Applicant One)

I Agree (Applicant Two)

By checking this box, I hereby agree to directly provide or otherwise request that my providers release any and all health information related to fertility treatments, including information relating to any medical history, which I understand may include genetic information, mental health information, substance use information, and information related to communicable diseases, such as HIV/AIDS, to pkDO (the privacy and security of your health information is a priority at pkDO). *

I Agree (Applicant One)

I Agree (Applicant Two)

By checking this box, I hereby authorize pkDO to share any and all health information related to fertility treatments, including information relating to any medical history, which I understand may include genetic information, mental health information, substance use information, and information related to communicable diseases, such as HIV/AIDS, with Partner Fertility Clinic. *

I Agree (Applicant One)

I Agree (Applicant Two)

By checking this box, I hereby commit to beginning the IVF process within 1 year of the approval of this application. *

I Agree (Applicant One)

I Agree (Applicant Two)

By checking this box, I hereby agree that pkDO is not liable for any results, including, but not limited to, the failure to have a baby, the failure of an embryo to implant, any results of the viability study, or any complications that may result from the processes and procedures, including, but not limited to, the viability study, pregenetic testing, and/or IVF.

I Agree (Applicant One)

I Agree (Applicant Two)

Please refer to the below link for a sample copy of the Grant Agreement for full terms and conditions of the grant, if awarded. PKD Outreach Foundation may either award or reject this application at its sole discretion, with or without cause or reason. Awarded grants will be paid directly to your Fertility Clinic on your behalf. We will notify you if your application is approved and, if approved, when grant money is transferred to the Fertility Clinic. PKD Outreach Foundation does not discriminate on the basis of race, color, religion (creed), gender, gender expression or identification, age, national origin (ancestry), disability, marital status, sexual orientation, military status, or any category protected by federal, state, or local law. Any and all grant applications are determined without consideration to the above factors. The decision of PKD Outreach Foundation is final and is not subject to a review process.

Section 7. Attestation:

I solemnly swear that my answers to the questions listed above are true and correct. PKD Outreach Foundation reserves the right to demand repayment of the grant amount in the event any of the above answers are untrue or incorrect.

IVF Applicant #1 - (Please use your mouse or trackpad to digitally sign below):

Signature *

Clear

Applicant #1 Full Name

Date

IVF Applicant #2 - (Please use your mouse or trackpad to digitally sign below):

Signature

Clear

Applicant #2 Full Name

Date