AFAZ Support Request

The Abortion Fund of Arizona is a program of FLORECER: Reproductive Justice, offering financial assistance for abortion expenses and logistical support. Please complete the request for contact form below, and a volunteer from our team will connect with you as soon as possible. Our volunteers return calls on Mondays, Tuesdays, Thursdays, and Fridays.

*Submitting this form does not guarantee funding. A member of our team will reach out to speak with you directly to discuss funding availability and possible pledge amount. We appreciate your patience!

This form should be completed only by the person seeking support. Thank you!

Today's date: *

First name, last initial: *

Pronouns (ex: she/her, they/them, he/him):

Contact number: *

This number is: *

Specific reach out instructions, if needed:

Region traveling from *

How many weeks gestation are you? (Best estimates are okay!) *

I am seeking: *

Information on where to start / guidance on the abortion process Abortion procedure funding Travel/practical expense support Another AFAZ / Florecer Reproductive Justice program

Please send me resources for the following:

Arizona abortion clinics & funds Neighboring state abortion resources (NV, NM, CA, CO) Later-care abortion resources (NM, CO, WA, D.C.) Community resources - violence support, food, know your rights, emotional support, and more Housing resources

Best email to send resources:

Appointment Information

While we encourage you to have an appointment set up, it is okay if you don't have one yet! A member of our team will meet you wherever you are at with the process.

If you do not have an appointment scheduled, please continue through the rest of this intake to submit your request!

Appointment date:

This appointment is in

This appointment is for:

What is your total procedure cost (before any assistance)?

Have you received funding from the National Abortion Federation (NAF)?

The National Abortion Federation (NAF) is a nationwide funding resource with clinic partnerships across the US. Those that qualify may receive coverage up to 50% of the total abortion procedure cost as well as support with travel expenses.

*See help bubble to right for NAF contact information

Have you received funding from the Tucson Abortion Support Collective (TASC)?

The Tucson Abortion Support Collective (TASC) is an abortion funding resource for folks living in southern Arizona.

*See help bubble to right for TASC contact information

How much can you contribute towards the expense?

Remaining balance to gather after all contributions:

Is there anything else you'd like to share?

Have you been or consider yourself to be unhoused in the last 6 months?

If yes, what kind of houselessness are you/were you experiencing?

Living outside Living in car Living temporarily with others Some time in a shelter Other: please write below

If other, please elaborate:

Under our larger body of work, Florecer Reproductive Justice, we've been setting the groundwork for the new Saguaro Relief Program, devoted to supporting pregnant individuals who are experiencing homelessness or housing insecurity. We are currently in the dreaming stage of what this support could look like, and want to hear from the community.

By checking this box, I'd like to be connected to someone from AFAZ / FRJ in regards to the Saguaro Relief program, to share my experience and vision for better support for the community