General Funding Form "*" indicates required fields Accept Terms and Conditions:*Please make sure you have all of the following available before progressing to the next step. I have read and understand the terms and conditions. I have Rabbi’s consent form ready I have 3 months bank statements ready I have 3 months payslips ready I have 3 months credit card statements ready I have a rent/bond statement ready I have a Ketubah and civil marriage certificate ready I have my financial details spreadsheet ready Rabbi's Consent Form*Accepted file types: pdf, pdf, xls, xlsx, doc, docx, Max. file size: 5 MB.3 Months Bank Statements* Drop files here or Select files Max. file size: 5 MB. For both of you (if separate)3 Months Credit Card Statements* Drop files here or Select files Max. file size: 5 MB. For both of you (if separate)Hidden3 Month Pay Slips (old)Max. file size: 5 MB.For both of you.3 Month Pay Slips* Drop files here or Select files Max. file size: 5 MB, Max. files: 6. For both of you.3 Month Bond/Rent Statement* Drop files here or Select files Max. file size: 5 MB, Max. files: 6. Ketubah and Civil Marriage Certificate* Drop files here or Select files Max. file size: 5 MB, Max. files: 2. Financial Details Spreadsheet*Max. file size: 5 MB.Income Status* Both of us earn an income One of us earns an income Neither of us earns an income Wife's Name* First Last Wife's Hebrew Name* Wife's Mother's Hebrew Name* Wife's Father's Hebrew Name* Wife's Date of Birth* DD slash MM slash YYYY Wife's Cell Phone Number*Wife's Email* Wife Born Jewish?* Yes No Where were you converted (which Rabbinical court)* When were you converted?* MM slash DD slash YYYY Do you attend Mikveh regularly?* Yes No Husband's Name* First Last Husband's Hebrew Name* Husband's Mother's Hebrew Name* Husband's Father's Hebrew Name* Husband's Date of Birth* DD slash MM slash YYYY Husband's Cell Phone Number*Husband's Email* Husband Born Jewish?* Yes No Where were you converted (which Rabbinical court)* When were you converted?* DD slash MM slash YYYY Date of Marriage* DD slash MM slash YYYY Do you both keep Shabbas and Kashrut?* Yes No Which shul do you attend?* Your Rabbi's Name* RabbiRabbiRabbi Dr Prefix Last Is your Rabbi aware you are undergoing fertility treatment?* Yes No Fertility Doctor's Name* First Last Fertility Clinic* Fertility Doctor's Phone*Fertility Doctor's Email* Medical Aid* We have medical aid. We do not have medical aid. Medical Aid Provider* Medical Aid Plan* Medical Aid Number* Have you had any fertility procedures / treatments before? Yes No When did you start treatment?* DD slash MM slash YYYY Was this treatment at a clinic different to your current clinic?* Yes No Fertility Doctor's Name* First Last Fertility Clinic* Which fertility procedures have you had?What was the approximate cost of past procedures?*Which fertility procedure will you be having* AI IVF ICSI GIFT Donor Egg Donor Sperm Surrogacy Do you have any children?* Yes No How many children?*Please enter a number from 1 to 10.Are any of your children adopted?* Yes No Age of First Child*Age of youngest Child*Which child is adopted?*How old is the adopted child?*Please disclose any additional information which may be helpful or important to us addressing your application:I declare that the information provided is accurate and complete to the best of my knowledge* Wife’s Declaration Husband’s Declaration Ohel Sarala is an initiative in which couples struggling with infertility & single woman struggling to get married daven for each other. Please indicate if you would you like to be part of this initiative. Complete confidentiality is assured as only hebrew names are shared.* Yes No
