BILL PICKETT INVITATIONAL RODEO FOUNDATION

BILL PICKETT INVITATIONAL RODEO FOUNDATION
BPIR Crisis Assistance Fund—Member Application
Confidential
BPIRF CRISIS ASSISTANCE GRANT
Member Application Form
Bill Pickett Invitational Rodeo Foundation
IMPORTANT — Please read before completing this application
This application is for current BPIR members experiencing financial hardship resulting directly from a competition- related injury or qualifying crisis event. Assistance of up to $2,000 is available to help cover essential living expenses (housing, utilities, food) during the recovery or crisis period. All applications are reviewed by the BPIR Foundation Committee. Decisions are final and subject to available fund resources. Submit all required documentation with this form.
SECTION 1 — APPLICANT INFORMATION
First Name & Last Name

First NameLast Name
BPIR Member Number
Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
Mailing Address (Street, City, State, ZIP)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Rodeo Discipline / Event(s)
Years Competing with BPIR
SECTION 2 — NATURE OF CRISIS OR INJURY
Date of Injury or Crisis Event (MM/DD/YYYY)

MonthDayYear
Date
Location / Event Name
Type of Crisis or Event:
BPIR Crisis Assistance Fund Confidential Page 1 of 4

BILL PICKETT INVITATIONAL RODEO FOUNDATION
BPIR Crisis Assistance Fund - Member Application Confidential
Describe the injury or crisis event in detail: (Include how it occurred, body parts affected, and whether medical attention was received)
How has this affected your ability to compete and earn income?
SECTION 3 — FINANCIAL HARDSHIP STATEMENT
Essential expenses you are currently unable to meet (check all that apply):
Describe your current financial hardship in detail: (Include household income status, dependents, and any other relevant financial context)
SECTION 4 — ASSISTANCE REQUESTED
Amount of Assistance Requested ($)
Anticipated Recovery / Crisis Duration (weeks/months)
BPIR Crisis Assistance Fund | Confidential | Page 2 of 4

BILL PICKETT INVITATIONAL RODEO FOUNDATION
BPIR Crisis Assistance Fund—Member Application Confidential
Describe specifically how the funds will be used: (e.g., two months' rent, utility reconnection, grocery costs during recovery)
SECTION 5 — SUPPORTING DOCUMENTATION CHECKLIST
Please indicate which documents you are submitting with this application:
Additional documentation notes: (List any documents enclosed that are not checked above, or explain any documentation you are unable to provide)
SECTION 6 — CERTIFICATION & SIGNATURE
By signing below, I certify that:
1. All information provided in this application and all attached documents is true, accurate, and complete to the best of my knowledge.
2. I am a current BPIR member in good standing.
3. The injury or crisis described herein is directly related to BPIR competition or a qualifying event.
4. I understand that this fund provides limited, one-time financial relief and that all decisions made by the BPIR Foundation Committee are final.
5. I authorize the BPIR Foundation Committee to verify the information provided in this application, including contacting medical providers or other relevant parties as needed.
6. I understand that submitting false or misleading information may result in disqualification from this and future assistance programs.
Applicant Signature
Date Signed

MonthDayYear
Date
Printed Name
BPIR Crisis Assistance Fund Confidential Page 3 of 4

BILL PICKETT INVITATIONAL RODEO FOUNDATIONBPIR Crisis Assistance Fund—Member Application Confidential
HOW TO SUBMIT YOUR APPLICATION
Submit this completed form along with all supporting documentation to the BPIR Foundation Committee at
billpickett.rodeo@gmail.com.
Bill Pickett Invitational Rodeo Foundation | BPIRF Crisis Assistance Grant
The Committee will contact you to confirm receipt and communicate a decision in a timely manner.
For Committee Use Only
Application Received
Committee Decision
Date Notified
BPIR Crisis Assistance Fund | Confidential | Page 4 of 4
Should be Empty:

BILL PICKETT INVITATIONAL RODEO FOUNDATIONBPIR Crisis Assistance Fund—Member Application Confidential