Bridge Ministry of Burton, Texas
Community Survey

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
telephone number?
___________________________________________________________________________________
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
___ Water/Sewer
___ Electricity
___ 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 • burtonbridgeministry@gmail.com • 979-337-3370