Fertility Preservation The Funding ProcessCollect DocumentationSubmit Application Fertility Preservation Application 1Terms & Documents2Personal & Religious3Medical Information4Declarations CommentsThis field is for validation purposes and should be left unchanged.Terms & Required DocumentsTerms & Conditions(Required) I have read and accept the Terms & Conditions and have prepared the required documents listed below. Agreement Letter(Required)Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB. Rabbi's Consent Form(Required)Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB. Motivation Letter from Treating Doctor (with blood results)(Required) Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB, Max. files: 3. 3 Months' Bank Statements(Required) Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB, Max. files: 6. 3 Months' Credit Card Statements Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB, Max. files: 6. 3 Months' Salary Slips Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB, Max. files: 6. 3 Months' Bond / Rent Statement Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB, Max. files: 6. Financial Details Spreadsheet(Required)Accepted file types: pdf, xls, xlsx, Max. file size: 10 MB. Your DetailsYour Name(Required)Your Hebrew Name(Required)Your Mother's Hebrew Name(Required)Your Father's Hebrew Name(Required)Your Date of Birth(Required) DD slash MM slash YYYY Cell Phone(Required)Email(Required) Income Status(Required) I earn an income I do not earn an income Religious StatusWere you born Jewish?(Required) Yes No Where were you converted? (Rabbinical court)(Required)Conversion date(Required) DD slash MM slash YYYY Do you observe Shabbos and Kashrut?(Required) Yes No Which Shul do you attend?Rabbi's Name(Required)Is your Rabbi aware of your treatment?(Required) Yes No Medical InformationFertility Doctor's Name(Required)Fertility Clinic(Required)Doctor's Phone(Required)Doctor's Email(Required) Do you belong to a Medical Aid?(Required) Yes No Medical Aid provider(Required)Medical Aid plan(Required)Have you frozen oocytes (eggs) before?(Required) Yes No If yes, approximately when?(Required)Approximate cost of previous freezing (ZAR)Any additional medical information? DeclarationsDeclaration of Accuracy(Required) I declare that the information provided is true and correct to the best of my knowledge. Would you like to participate in the Ohel Sarala initiative?(Required) Yes No Privacy & POPIA Consent(Required) I have read the Privacy Policy and consent to Malka Ella processing the personal information in this application. Malka Ella collects this information solely to assess and administer your application. See our Privacy Policy for how we handle, store and retain your personal information.
