Bridge Ministry of Burton, Texas
Please complete the information below so that we can notify you about grant funding opportunities, extra food distributions or programs that serve the community. Print this page and send it to us.
Your name: _________________________________________________________________________
Your telephone number: _______________________________________________________________
Your mailing address: ________________________________________________________________
If we can’t reach you by phone, is there a neighbor or relative we can call? What is their name and
In what county do you live?
__ Washington ___ Burleson ___ Brazos ___ Robertson ___ Grimes ___ Leon
___ Madison ___ Lee ___ Fayette ___ Austin ___ Waller
Have you lost your job or had your hours cut because of the COVID-19 crisis? ___ yes ___ no
Where did you work? _________________________________________________________________
Are you 65 years of age (or older)? ___ yes ___ no
Do you have medical issues like heart disease, diabetes, cancer, or a weakened immune system? ___ yes ___ no
Do you need help with any of the following?
___ Rent or mortgage
___ Liquid propane
___ Gas for your vehicle
___ Topping up your phone. Your cell phone provider is ______________________________________
Please return this form to Bridge Ministry of Burton, Texas no later than Wednesday, June 3, 2020.
Bridge Ministry of Burton, Texas • P.O. Box 68, Burton, Texas 77835
www.burtonbridgeministry.org • email@example.com • 979-337-3370