Trans and GNC Medical Needs Fund - Fresno EOC

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LGBTQ+ Resource Center
Trans and GNC Medical Needs Fund

Trans and GNC Medical Needs Fund Form

Provided by Fresno EOC LGBTQ+ Resource Center and Community Members like YOU!

This fund provides financial support for medical needs related to gender affirming care:

Binders, prosthetics, and other gender affirming accessories
Co-pays and bills associated with gender-related care
Travel costs associated with receiving gender-related care
Bills associated with recovery time after gender affirming surgery

If you have any difficulty accessing this form, please email lgbtq@fresnoeoc.org or call/text (559) 325-4527.

LGBTQ+ - Trans and GNC Medical Needs Fund Form

Name you go by (preferred name):*
First
Legal name:*
First Last
Gender Identity:*
Pronouns:
- They/them
- They/he
- They/her
- He/him
- She/her
Date of Birth:
Email Address:*
Phone:*
Address*
Street Address Address Line 2 City State ZIP
Preference for receiving financial aid if selected:*
If pick up, address for pickup will be provided
- Mail
- Pick up
Mailing address (if different from above):
If completed, financial aid will be mailed to this address, rather than the address provided above.

Street Address Address Line 2 City State ZIP
This field is hidden when viewing the form
Address you wish for financial aid to be sent if selected:
(If you wish to pick up, please put PICK UP in answer section. Address for pick ups will be provided)
Do you live in Fresno County?*
- Yes
- No
What gender-related care are you requesting funds for?*
*For items over $50, proof of bill and/or appointment REQUIRED*
- Body Modification Clothing (binders, shapewear, etc)
- Prosthetics
- Medical Supplies
- Hotel stay for out-of-area care
- Gas and/or car rental for out-of-area care
- Food for out-of-area stay
- Doctor Appointment: copays, specialist care consultations, etc.
- Gender Confirmation Surgery
- Recovery time/out of work while recovering from Gender Confirmation Surgeries
- Mental Health Therapist Appointment(s)
- Other
If Other, what service(s) are you requesting?
Select the amount of financial assistance are you requesting?*
- $50
- $50 - $100 (Proof of need is required)
- $101 - $200 (Proof of need is required)
- $201 - $300 (Proof of need is required)
- $301 - $400 (Proof of need is required)
- $401 - $500 (Proof of need is required)
- $501 - $600 (Proof of need is required)
- $601 - $700 (Proof of need is required)
- $701 - $800 (Proof of need is required)
- $801 - $900 (Proof of need is required)
- $901 - $1,000 (Proof of need is required)
Select the form of assistance you would like to receive?*
- VISA Gift Card
- Check
- Payment directly to vendor (in instances where proof is provided)
When will you need this financial aid?*
- ASAP (Note - assistance could take up to 2 weeks for processing)
- 0 - 3 months
- 3 - 6 months
- 6 - 12 months
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