The R.O.S.E. Fund Surgery Program Application

The R.O.S.E. Fund Scholarship Application

The R.O.S.E. Fund’s
Facial Reconstructive Surgery Program Application:

The R.O.S.E. Fund advances the transformation from victim to survivor by providing women with renewed confidence in their personal appearance and well being.

Partnering with surgeons nationwide, The R.O.S.E. Fund provides access to facial reconstructive surgery for survivors with facial disfigurements resulting from acts of domestic violence.

Regaining self-esteem is the focus of every R.O.S.E. initiative. The R.O.S.E. Fund hopes to empower women survivors with it to achieve self-sufficiency and to rebuild their lives.

Candidate eligibility is determined by and at the sole discretion of The R.O.S.E. Fund and its medical partners.

 

Application

Name
Address:
City
State
Zip Code
Telephone Number:
E-Mail:
Are you receiving public assistance?
Have you ever been arrested?
If yes please describe:

 

Employment

Are you employed?

 

If, yes please list job(s) below.

Start date End date Company Address Reason for Leaving
Start date End date Company Address Reason for Leaving
Start date End date Company Address Reason for Leaving

 

In the text box below, please describe the injury or disfigurement and how it happened in 100 words or less.

 

In the text box below please describe in 100 words or less how you overcame being a victim of domestic violence.

 

In the text box below please describe in 100 words or less to whom or what you turned for support as you moved ahead as a survivor?

 

In the text box below please describe in 100 words or less how you will thrive and reach for your dreams after surgery.

 

Check the box next to each statement if you are in compliance

I have suffered a facial injury as a direct result of domestic violence
I can not otherwise afford this surgery
I agree to release all required information to The R.O.S.E. Fund and its medical partners
I will sign a waiver of any claim(s) against The R.O.S.E. Fund and/or the partner hospital and/or surgery center and/or physician, arising from any of the services provided.
I have been out of an abusive relationship for at least one year
I am living in a safe place
I am a U.S. citizen or legal resident

 

In the text box below, please list two people you know who will swear that you have been out of an abusive relationship for at least one year and are living in a safe place. Have each write, sign and send a letter stating as much to: The R.O.S.E. Fund 200 Harvard Mill Square Wakefield, MA 01880

Check the box next to each mandatory supplement item AFTER you have mailed copies of it to

The R.O.S.E. Fund 200 Harvard Mill Square Wakefield, MA 01880

Police reports and all relevant information
Hospital/ doctors reports and all relevant information
Financial aid packet(s) indicating that you cannot afford surgery
Your most recent tax return (or your parents’ if you are dependent).

All materials will be held confidential by The R.O.S.E. Fund and the partner hospital and/or surgery center and/or physician unless otherwise authorized by applicant.

All final applicants will be required to complete medical forms mandatory to the partner hospital and/or surgery center and/or physician and obtain final approval for surgery from the hospital and/or surgery center and/or physician.

Please mail mandatory supplement material to:

The R.O.S.E. Fund
The R.O.S.E. Facial Reconstructive Surgery Program
200 Harvard Mill Square
Wakefield, MA 01880

I agree that all the information on this application is complete and accurate. My electronic signature also serves as a release for The R.O.S.E. Fund to obtain medical records, police records and other information relevant to my application. My electronic signature is further in acknowledgment of my express waiver of any and all claims against The R.O.S.E. Fund for any injury or loss directly arising or directly relating to the surgeries performed by the hospital provider and/ or surgery center and/ or physician.

 

 

 

Candidate eligibility is determined by and at the sole discretion of The R.O.S.E. Fund and its educational partners.

The R.O.S.E. Scholarship

R.O.S.E. Scholarships advance the transformation from victim to survivor by funding a woman’s career training and professional development. Partnering with academic institutions nationwide, The R.O.S.E. Fund assists with the cost of:

  • Tuition
  • Books
  • Other costs directly related to your education.

Application

Name
Address:
City
State
Zip Code
Telephone Number:
E-Mail:
Name of school attended/attending
Phone Number
Are you receiving public assistance?
Have you ever been arrested?
If yes please describe:

 

Employment Information

Are you employed?

 

If, yes please list job(s) below.

Start date End date Company Address Reason for Leaving
Start date End date Company Address Reason for Leaving
Start date End date Company Address Reason for Leaving

 

Check the box next to each statement if you are in compliance

I have been out of an abusive relationship for at least one year
I am living in a safe place
I have completed at least one year of college

 

In the text box below, please list your accomplishments including

volunteer work
extra-curricular activities
honors received
awards won
articles written by you
articles written about you.

 

Check the box next to each mandatory item AFTER you have mailed copies of it to

The R.O.S.E. Fund 200 Harvard Mill Square Wakefield, MA 01880

high school diploma / GED certificate
high school transcript
college transcript
financial aid packet(s)
other scholarships awarded
your most recent tax return (or your parents’ if you are dependent).

 

In the text box below, please list three written references, two from teachers, one personal, as well as the number of years you’ve known each person and a brief description of your relationship with him/her. References must be sent to:

The R.O.S.E. Fund 200 Harvard Mill Square Wakefield, MA 01880.

 

In the text box below please describe in 100 words or less how you overcame being a victim of domestic violence.

 

In the text box below please describe in 100 words or less to whom or what you turned for support as you moved ahead as a survivor?

 

In the text box below please describe how you will thrive and reach for your dreams with The R.O.S.E. Fund helping to fund the completion of your college degree.

 

Please indicate with a check that you understand and agree to the following:

Final applicants may be interviewed at The R.O.S.E Fund’s office in Wakefield, Mass.
Recipients maintaining 2.5 GPA are given preferential treatment for renewable scholarships
I agree that all the information on this application is complete and accurate. My electronic signature also indicates my permission to release all information contained in my application as well as relevant information from current or past educational institutions. If awarded a scholarship, I consent to giving The R.O.S.E. Fund access to my grades to assure compliance with scholarship requirements