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- Info
Every Woman's Life Application
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The EWL application is available in Microsoft Word and Acrobat
format. Please click on the links below to download the application as
needed. Feel free to copy as many as needed.
Download Application Forms:
Eligibility Form
(.pdf)
Appointment Choices
(.doc)
Consent Form
(.doc)
Client Participation
Agreement (.pdf)
Completed applications (for women who wish to be seen in the
Albemarle, Charlottesville, Greene, Louisa, Madison, Orange and
surrounding area)
may be faxed to our office at (434) 243-9784 or mailed to:
Every Woman's Life
University of Virginia Health System
P.O. Box 800334
Jefferson Park Avenue
Charlottesville, VA 22908
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Completing an application does NOT guarantee acceptance into the
program. EWL Staff must receive and review all applications to
determine eligibility.
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INCOMPLETE OR PARTIAL APPLICATIONS
CANNOT BE PROCESSED.
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PLEASE COMPLETE THE ENTIRE APPLICATION AND ANSWER ALL QUESTIONS TO THE
BEST OF YOUR ABILITY.
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Virginia BCCEDP
2012 Federal Poverty Guidelines
(Effective 2/1/12 through 1/31/13)
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Household Size
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Gross Yearly
Salary
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Gross Monthly
Income*
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Approximate Hourly
Income**
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1
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$22,340
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$1,861.00 |
$10.74
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2
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$30,260
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$2,521.00 |
$14.55
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3
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$38,180
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$3,181.00 |
$18.36
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4
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$46,100
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$3,841.00 |
$22.16
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| 5 |
$54,920 |
$4,501.00 |
$26.40
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6
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$61,940
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$5,161.00 |
$29.78
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| 7 |
$69,860 |
$5,821.00 |
$33.59
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| 8 |
$77,780 |
$6,481.00 |
$37.39
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For each
additional
person, add: |
$7,920 |
$660.00 |
$3.81 |
*Yearly income divided by 12 Months
**Assumes a full-time job for a full year (2080 hours)
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