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.