“BRCA” is an abbreviation for “breast cancer” and two different BRCA genes have been found to impact a person’s likelihood of developing breast, ovarian, and prostate cancer. While they do not cause various cancers, the presence of these genes, especially if mutated, can signal the gene’s ability or inability to repair broken DNA which may then cause cancer. The Jody Lynne Jackman Foundation (“Foundation”) is a 501(c)3 tax-exempt nonprofit organization domiciled in the state of Nevada. Its mission is to educate the general public about the BRCA gene and provide financial support for testing for the BRCA genes for early detection and treatment of the various cancers that can be caused by the BRCA gene.

The Foundation is offering financial support for BRCA testing to those who cannot afford the associated fees. A completed and signed application is required to determine your eligibility for financial support. Note that financial support is limited to the actual BRCA test only, and will not include doctor visits or any other associated costs beyond this one test. By submitting this application, you acknowledge that:

1)    The Foundation is neither a “covered entity” nor a “business associate” under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and therefore is not required to comply with its provisions;

2)    That you are not required to provide the Foundation with any information about yourself or your medical history;

3)    The Foundation is collecting this information only to determine your eligibility for financial support for BRCA testing.

4)    The Foundation is not offering medical advice or providing any guarantees or representations regarding results of BRCA testing and subsequent treatment.

5)    Even if you are approved for financial support, the Foundation cannot and does not guarantee ongoing or future support; this application is for financial support for a one-time BRCA test.

6)    You hereby expressly waive any and all claims against the Foundation, its officers, directors, agents, and representatives, for damages or compensation.

7)    Any controversy or claim arising out of or relating to this application or any subsequent actions or non-actions by the Foundation, shall be settled by binding confidential arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association (“AAA”). Judgment upon the award rendered by the arbitrators may be enforced in any court having jurisdiction thereof.