Minnesota Knights of Columbus
Global Wheelchair Mission Form
Council Number __________________
Location (City) ___________________________________________________
Church Drive
Date of your council’s Wheelchair Church Drive: ___________________________________________________________
The total dollar amount of donations received during this Wheelchair Church Drive: $______________________
How many new members were inspired to join your council as a result of the presentation? _________
Other Fundraising Activities for the Global Wheelchair Mission
Briefly describe any other activities your council did to raise funds for the Global Wheelchair Mission
(e.g.: Pancake Breakfast, Car Wash, Dinner/Dance, etc.) Use back if needed:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Total dollar amount raised during other fundraising activities: $______________________
Total number of man-hours donated to raise funds for this wheelchair order: __________________
How many new members were inspired to join your council as a result of these activities? _________
________________________________________________________________________________________________________
Wheelchair Order
Total dollar amount of donations for this order: $______________________
Number of wheelchair(s) ordered for distribution in Minnesota @ $150.00 each: __________________
Size and number of chairs requested by council: _____ 14 inch
_____ 16 inch
_____ 18 inch _____ 20 inch
COUNCIL WILL BE RESPONSIBLE FOR PICKING UP THE CHAIRS THEY ORDER.
Number of wheelchair(s) ordered for distribution in Columbia, South America @ $150.00 each: __________________
Make checks payable to Minnesota Knights of Columbus with Global Wheelchair Mission on the memo line.
For tax purposes, private donations or gambling funds may make checks payable to Minnesota Knights Foundation.
Date: _____________________________ Grand Knight: ___________________________________________________
Phone #: _________________________________ Email: ___________________________________________________
Address: ___________________________________________________________________________________________
City: _______________________________________________ State & Zip: ___________________________________
Send the completed form and check to the Minnesota Knights of Columbus State Secretary.
See the State Newsletter or visit for his address.
Allow up to 4 months for delivery schedule. You will be notified of date and location for wheelchair pickup.