Winneshiek County Celebration of Life
Fuel/Grocery Grants
Application Form for Fuel/Grocery for the Fight
Nomination Form
Winneshiek County Celebration of Life, a not for profit organization, is dedicated to the health and well being of individuals in our area. Our mission is to promote awareness and early detection of disease through education and financial support of preventive and screening services. Through the generosity of local businesses, individuals and memorials, we are able to provide this grant program.

Please nominate someone you may know, or even yourself, that could benefit from our program. Please complete the entire form.
Nominees Name: *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Family Doctors Name
If not a resident of Winneshiek County
Your answer
To the best of my knowledge the nominee is:
● Male or Female
● Age of 18 and older
● In active treatment for cancer
● and is either a resident of Winneshiek County, or his/her family doctor is located in Winneshiek County.
I understand that they may receive a one time $200 value gasoline card and $100 grocery card on a first come first serve basis. If WCCOL's designated funding is exhausted by December, new grant monies will be available in January of the next year. *
Required
Your Name *
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Phone Number *
Your answer
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