I.W.I.N. Foundation

Client Application

If you are interested in taking advantage of the services I.W.I.N. has to offer, please fill out the information below and hit the 'Submit Form' button.

First Name
Last Name
Middle Initial
Street Address
City
State
Zip Code
Work Phone
Home Phone
E-mail
Date of Birth

Please select the services that would be most beneficial to you:
	Personal Errands
	Childcare
	Housekeeping
	Lawn Maintenance
	In-Home Pet Care
	Massage Therapy
	Photography Services
	Meal Preparation
	Yoga Classes
	Exercise Classes

Supervising Physician
Physician's Address & Phone Number

Current therapy (please check all that apply):

Chemotherapy		Radiation	Surgery

I consent to IWIN contacting my supervising physician to verify that I have breast cancer and to verify my treatment. I understand that IWIN Foundation only provides financial assistance for the services that I may receive. I agree that if I am an IWIN Foundation recipient, IWIN Foundation is not responsible for the services that I may receive and I will not hold IWIN Foundation liable for any damages or claims that I may have as a result of the services. By clicking the 'Submit Form' button below, I indicate my agreement with the above.

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