Medical Assistance Grant Application - Eastern PA Transgender Equity Project

Chosen Name*

First Last

Legal Name*

First Last

Pronouns

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

Phone Number*

County of residence*

What type of assistance are you seeking funds for (note: you must have a valid prescription from a licensed healthcare provider)?*

Feminizing Medications
Masculinizing Medications
healthcare provider copay

What is the cost of your copay or medication (note: you must have a price quote from your pharmacy)

What is your nearest pharmacy?*

Select All
CVS
Walgreens
Rite Aid

Ethnicity or Race*

Asian
Black/African American
Caucasian/White
LatinX/Hispanic
Native American
Pacific Islander
Other
Prefer not to say

Age*

Are you currently employed?*

Yes
No

If employed, who is your employer?

How many people reside in your household?*

What is your current monthly household income (for all members of the household)?*

What are the current monthly expenses for the household (for all members of the household)?*

How did you learn about this Program?*

Are you able to provide documentation of your income or expenses if requested (screen shots/documents)*

Yes
No

Are you enrolled in any of the following assistance programs?*

SSI
SSDI
TANF / Welfare
LiHeap/ Utility or Heating Assistance
SNAP / Food Stamps
CHIP or Medicaid
Housing Choice Voucher Program
None

If you chose "Other" or "Referred by an Agency" please describe:

In 2-3 sentences, please describe your shelter, food, clothing, and health needs at this current stage of your life

Please provide information about your background as a transgender person.*

Have you ever applied for a grant from Eastern PA Trans Equity Project in the past?*

Yes
No

If you answered "yes," what type of grant did you apply for?

Is there any other information the Grant Committee needs to make a decision?

Would you like to receive our monthly newsletter and other updates?

Yes
No

I affirm that I am a transgender/gender diverse person or the parent of a transgender child. I furthermore affirm that the information in this application is true and accurate. I agree that any funds or gift cards I receive will be used exclusively for food and sustenance for me or my family*

Click to affirm

Medical Assistance Application