Images of Hope

Applicant Information

Name*

Prefix First Last Suffix

Do you require a Spanish-speaking translator? ¿Necesita un traductor que hable español?*

Yes
No

Birthdate*

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

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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.

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