Application Form

The Family Fertility Fund of Saskatchewan Incorporated
PO Box 843
Dundurn, SK
S0K 1K0

This application is for Saskatchewan residents ONLY

ALL APPLICANTS MUST SUBMIT A NON REFUNDABLE $20 FEE PAYABLE TO: The Family Fertility Fund of Saskatchewan Incorporated. All electronic transfers can be sent to: Info@familyfertilityfund.com with question “What for?” and answer “funding.” Please note: The application is now a two part process. This is a preliminary application to determine your eligibility and if you meet the required criteria. If you are preselected, a secondary application detailing your complete finances and full medical history will be required.
PLEASE NOTE: ALL APPLICATIONS ARE ACCEPTED THRICE A YEAR, MARCH 1-31 IS THE DEADLINE FOR APRIL FUNDS, JULY 1-31 FOR AUGUST FUNDS AND NOVEMBER 1-30 FOR DECEMBER FUNDS. ALL APPLICATIONS ARE CONSIDERED ONCE PER CYCLE. YOU MUST RESUBMIT TO BE RECONSIDERED FOR FUTURE ASSISTANCE.

MEDICAL INFORMATION

What medications do you currently take (please include all Supplements, Vitamins, Remedies etc.)

CURRENT EMPLOYMENT

Please list your assets and debts, along with monetary amounts

Applicant

Co-Applicant

Household Budget

Please list approximate spending on the following and choose the appropriate time frame. Refer to your bank statements for accuracy.

Mortgage

Taxes (Property, mortgage etc.)

Insurance (life, home, auto)

Car Payments

Hydro

Water

Energy

Cable and/or Internet

Credit Cards

Loans

Daycare/Child Care

Medical Expenses/Prescriptions

Groceries

Eating Out

Entertainment

Misc Needs (toiletries, gifts, haircuts, sundries etc.)

Home Maintenance

Yard Maintenance

Other

Your Fertility Journey

Who You Are

Privacy Policy

Family Fertility Fund of Saskatchewan Incorporated (“FFFS”) is committed to respecting the privacy of our applicants. We strive to provide a safe and secure user experience. This privacy policy (the “Privacy Policy”) is incorporated into and forms part of the terms and conditions governing the access and use of the services provided by FFFS through its webbased application to select a recipient to receive a $5,000.00 grant towards fertility treatments (the “Service”). This Privacy Policy sets forth the policies and practices that apply to the collection and usage of data through the provision of the Service. Your access and use of the Service constitutes your express and unconditional acceptance of all the terms and conditions of this Privacy Policy.

In particular, by submitting any personal information to FFFS you will be deemed to have given your permission for the use and disclosure of such personal information as described herein. Personal information includes, but is not limited to, your name, email address or phone number, banking records and medical records.

This Privacy Policy covers only the collection and use of personal information by FFFS through the provision of the Service. This Privacy Policy does not apply to the practices of companies or individuals that FFFS does not own or control. This Privacy Policy provides a description of the privacy and data use practices of FFFS (“us”, “we” or “our”) in connection with our receipt, collection and use of data and information from you as a user of the Service.

The Privacy Policy may be changed or updated from time to time. If the Privacy Policy is changed or updated such changes or updates will be posted to our website http://www.familyfertilityfund.com/ so that you will always know what information we gather, how we might use that information, and to whom we will disclose it.

Collected Personal Data

We generally collect the following types of information (collectively, the “Personal Data”) through the provision of the Service:

• Personal information – We may collect certain personal information including, but not limited to, your name, address, email address, telephone numbers, contact information, and other similar information from which your identity is discernible; and

• Records- We may collect certain confidential records including, but not limited to, your banking records, credit card statements and your medical records. This Privacy Policy applies solely to Personal Data we collect through the provision of the Service, and does not apply to information we collect in any other fashion. Protection of Personal Data We strive to protect your Personal Data from unauthorized access, use, or disclosure using reasonable technical and organizational measures designed to secure your personal information from accidental loss and from unauthorized access, use, alternation or disclosure. However, the use of such measures is not, and should not be considered to be, any type of guarantee or warranty by us that your Personal Data will not be accessed by third parties or that third parties will never be able to defeat those measures or use your personal information for improper purposes.

ADDITIONAL CONSENT

By submitting this application and signing below, the applicant(s) understand and consent to the following (Put a checkmark beside each statement and sign below):

I give permission for The Family Fertility Fund of Saskatchewan Incorporated to contact my physician and/or clinic’s business manager.
I/We pledge that all information we have given is correct and truthful. We understand the importance of honesty and transparency to be considered a candidate for this opportunity.

We strive to be diverse in regards to ethnicity, sexual orientation, personal story and geography. Please note that The Family Fertility Fund of Saskatchewan will not cover travel fees, accommodations or any other required funds necessary for out of province treatments although we will fund treatments in other provinces. Similarly, we do not provide funds for out of country treatments.

We only accept applications between the windows of March 1-31, July 1-31 and November 1-30. Any applications received outside this timeline will not be considered and you will have to resubmit.