Electrolysis Support Program Applications

Apply for Financial Assistance through the Electrolysis Support Fund
Point of Pride’s Electrolysis Support Fund provides financial assistance towards permanent hair removal services (including electrolysis and laser hair removal) for trans folks who cannot otherwise afford them. The full details of the program may be found on our website.
Your name (as you wish to be addressed)*

First NameLast Name
Your email*
example@example.com
Your phone number
Please enter a valid phone number.
What pronouns do you use?*

He/Him/HisHy/Hym/HysShe/Her/HersThey/Them/TheirsXe/Xem/XyrZe/HirNoneWrite in my own
Location*

Street Address

Street Address Line 2

CityState

Zip Code
Support Person

Some applicants need extra support with their application due to language barriers, disability, inconsistent access to Internet, or other factors. If you'd like to name a support person, you may do so below. Both you and your support person will be included on all emails regarding your application, so it's important that you select a support person that you trust. If you'd like to revoke or update your support person at any time, you may contact electrolysis@pointofpride.org to do so. Naming a support person is optional and will not positively or negatively affect your application status. If you do not wish to name a support person, please skip this section.
Support Person's name

First NameLast Name
Support Person's email
example@example.com
This is the same email address you listed for yourself above. We recommend providing a different email address for your support person.
Support Person's phone number
Please enter a valid phone number.
Your relationship to your support person*

Legal guardian to an applicant under the age of 18Accessibility supportEmotional supportTechnological/Internet supportTranslation supportOther

Demographic Info

The information collected in this section helps us identify additional grant and partnership opportunities, and better serve our applicants and community. Your responses will not affect your eligibility for this (or any other) Point of Pride program.
Your gender identity*

AgenderAndrogynousBigenderDemifemale/DemigirlDemimale/DemiboyGender Fluid/ Gender Queer/ GenderfluxGender Non-Conforming (GNC)IntersexNon-Binary (NB; Enby)Questioning/UnsureTrans Female (MtF; Male to Female; AMAB)Trans Male (FtM; Female to Male; AFAB)TransfeminineTransmasculineTwo-SpiritWrite in my own
Your age*
Do you have the consent of your parent/guardian to seek permanent hair removal services?*

YesNo
Please be sure that your parent/guardian that is providing consent is listed as your support person above.
Have you identified a provider and do you have their consent to receive permanent hair removal services?*

YesNo
Your ethnicity origin*

Aboriginal; Indigenous; Native; Native American/First NationsAsian; Pacific Islander; South-East Asian; IndianBlack or African AmericanHispanic or LatinxMiddle EasternWhitePrefer not to discloseWrite in my own
Your veteran/military status*

I am a US military veteranI am an active-duty US service memberI am not a member of the US militaryMy parent/guardian is a US military veteranMy parent/guardian is an active-duty US service memberMy partner/spouse is an active-duty US service memberPrefer not to disclose
Were you discharged (or in the discharge process) due to your gender identity?

YesNoPrefer not to disclose
Do you have any long-standing illness, disability, or infirmity? (Long-standing means anything that has troubled you over a period of time or that is likely to affect you over a period of time.)*

YesNoPrefer not to disclose
Have you applied for, or do you currently receive, government disability benefits (SSI/SSDI or your country's equivalent?)*

I receive government disability benefitsI've applied for government disability and am awaiting official determinationI've applied for government disability and my benefits were deniedI have chosen not to apply for government disability benefitsPrefer not to disclose
Are you a student?*

Yes - US Resident, In-State StudentYes - US Resident, Out of state StudentYes - US Resident, Studying InternationallyYes - International Resident, Studying in the USYes - International Resident, Studying within my home countryYes - International Resident, Studying outside of my home countryNo
What is the PRIMARY way you pay tuition?*

Self PayParent/Family PayFinancial Aid or GrantsStudent Loans
Are you the primary caretaker for another individual?*

Yes - A minor child or childrenYes - A disabled parent or older adultYes - A disabled partner or spouseNoPrefer not to disclose

Are you currently, or have you ever experienced...*

	Yes - Currently	Yes - In the Past	No - Never	Prefer not to disclose
homelessness or housing insecurity?
discrimination by your healthcare provider?
discrimination by an employer?
incarceration?

We strongly recommend that you read Section 3: Your Financial Need in the Electrolysis Instruction Packet before completing this question so you understand what our reviewers are looking for.

Notes:
- This is not an English test. We will NOT consider grammar/spelling or writing ability when reviewing your responses. Above all, please give us detailed, thorough responses so we understand your unique situation. This helps us understand the challenges and/or barriers to care you’ve faced when we are reviewing your application.
- If English is your second language, please respond in your native language. We will translate your answers. (Si el inglés es su segundo idioma, responda en su idioma nativo. Nosotros traduciremos sus respuestas.)
- To ensure a fair and unbiased review, applications are reviewed anonymously. In your written response, please do not include your name or other personally identifying information, such as your full name (chosen or legal), links to a personal website or GoFundMe page, links to social media pages, or anything else that could be used to determine who you are.
In 800 characters or less, please describe your current financial need and what receiving free or discounted hair removal services would mean for you.*

0/800

Apply for Financial Assistance through the Electrolysis Support Fund

Support Person

Demographic Info

Before You Submit

By clicking the button below, you submit your application. You will not be able to edit or update your application once it is submitted.