Images of Hope

Let's get you the assistance you need.

A mammogram is an image that helps prevent the premature death of women by detecting breast cancer at its earliest, most curable stage.

Women Rock, Inc. believes that all women deserve a chance to survive breast cancer through early detection. Images of Hope will provide free screening mammograms to under or uninsured women.

Interesting Facts

A screening mammogram can detect a breast cancer 1.7 years before it can be found on a breast self-exam.
Myth: a breast injury does not increase your chances of developing breast cancer.
Women aren’t the only ones at risk of developing breast cancer; men account for approximately 1% of breast cancer diagnoses.
Research suggests the more beer, wine or liquor a woman drinks the greater her risk for developing breast cancer.

Do you need assistance through Women Rock?

Apply for help

Images of Hope Preliminary Application

Applicant Information
Name*
Prefix First Last Suffix
Birthdate*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Mobile Phone*
Work Phone
Email*
Enter Email Confirm Email
Name of Primary Physician
Are you covered by health insurance, Medicare, or Medicaid?*
- Yes
- No
Which one?*
Marital Status*
- Married
- Single
- Divorced
- Widowed
Name of Spouse
First Last
Spouse's Phone Number
Spouse's Employer
Address
Street Address Address Line 2 City State ZIP Code
Are you employed?*
- Yes
- No
Employer*
Address*
Street Address Address Line 2 City State ZIP Code
Household Income and Family Size
Include any income received by yourself, spouse or any other individual living in your household. If you are living with someone you must disclose their income as well.

Please bring your most recent pay stub and/or income tax statement.
How many adults (age 18 or older) live in your household?*
How many children under the age of 18 live in your household?*
Net Employment Income*
Applicant Spouse Other
Welfare, SSI, SDI, etc.*
Applicant Spouse Other
Unemployment Compensation*
Applicant Spouse Other
Other (Child Support, etc.)*
Applicant Spouse Other
Demographic Worksheet
The data collected below is for statistical purposes only and is not considered when determining your eligibility for services rendered by Women Rock, Inc.
County of Residence
Select One
- Insured
- Underinsured
- Uninsured
Ethnicity
- American Indian or Alaska Native
- Asian
- Black or African American
- Hispanic or Latino
- Native Hawaiian or Other Pacific Islander
- White
Highest Level of Education
- High School/GED
- Associate Degree
- Bachelor's Degree
- Graduate or Professional Degree
- Some College
- Other
Additional Information and Acceptance
Needs Information
CAPTCHA
TERMS AND CONDITIONS*
- I agree
By accepting these Terms and Conditions, you agree and understand that the personal information you are submitting may be used by Women Rock, Inc. for internal record keeping as well as mandatory status reports required by the Wilson N. Jones Community Foundation for the Images of Hope program which you are applying to. Data collected and shared with this third party shall remain anonymous and will be presented for the sole purpose of substantiating the mission of Women Rock, Inc., which is to save lives by providing mammograms to those in need of our services.

Additionally, you understand that this form is only a preliminary step in the application process and does not guarantee you will qualify for funding through Images of Hope. Upon receipt and review of your preliminary application you will be contacted with additional instructions.

Women Rock, Inc. may require verification of income such as paystubs, income tax returns, etc. You agree to provide income verification when requested. You understand that by failing to provide information upon request, or if you have provided false information in order to obtain funding assistance from Women Rock, Inc., you will be required to pay the full cost of the services provided through Women Rock, Inc.

By submitting this form, you verify that all of the information is true and correct. You understand that false answers to any portion of this form may jeopardize any benefits you are receiving or will receive from Women Rock, Inc.
Email
This field is for validation purposes and should be left unchanged.

Images of Hope

Let's get you the assistance you need.

A mammogram is an image that helps prevent the premature death of women by detecting breast cancer at its earliest, most curable stage.

Women Rock, Inc. believes that all women deserve a chance to survive breast cancer through early detection. Images of Hope will provide free screening mammograms to under or uninsured women.

Interesting Facts

Do you need assistance through Women Rock?

Images of Hope Preliminary Application

Applicant Information

Household Income and Family Size

Demographic Worksheet

Additional Information and Acceptance