Date:__________________                 

 

Booker Mini Foundation Application

 

Booker Mini Foundation: Mission Statement: The mission of the BOOKER MINI FOUNDATION is to raise funds to assist families dealing with life threatening disease that significantly impacts their financial security. This assistance is targeted to families that reside in the following Southeast Minnesota counties. These counties include Olmsted, Winona, Fillmore, Goodhue, Mower, Wabasha and Dodge Counties. We ask that you fill out this form as completely as possible in order for our foundation to consider you for possible assistance. (Mail completed form to: Booker Mini Foundation, PO Box 5805, Rochester, MN 55903-5805) or email to GPete1951@aol.com                                                                       Thank you

 

 

Name:__________________________

Phone #:________________________


Address:________________________

 

_________________________


How long have you lived at this address? If less than two years, what was prior address:

 

 

 

 

What is the nature of your illness? (use additional pages if necessary)

 

 

 

 

 


What is the current prognosis? We require a copy of the Doctors medical report to be included with this application." (use additional pages if necessary)

 

 

 

 

 

 

If we are able to offer assistance, how would you plan on using the proceeds?

 

 

 

Are you currently enrolled in any medical assistance programs either thru the State or Federal government that would preclude you from accepting aid from the Booker Mini Foundation without leaving the State and Federal Government assistance programs?

 

Yes      or         No

 

 

What is your current financial status? (use additional pages if necessary)

 

 

 

 

 

 

 

 

Are you available for an interview by members of the Booker Mini Foundation?

 

Yes      or         No

 

If so what is the best way to reach you at to schedule this interview?

 

Phone______________________________________

 

E-mail______________________________________

 

 

 

If you are chosen to receive assistance can the Booker Mini Foundation have your permission to use your photo and story in publicizing the next fundraising event put on the by the Booker Mini Foundation.

 

Yes      or         No

 

This is not a requirement for receiving aid but rather a means of helping other families.

 

Use this space to provide us with any other information you wish to share with us: