Gift Card Acknowledgement Form
BCFS Health and Human ServicesHealth and Human Services Est. 1944
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Age
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Card Information #
Select Facilitator OR Advocate who handed the card.
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Please Select
Carolyn
Perry
Andrea J.
Elizabeth
Ema A.
Kristi J.
Cell Phone
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I acknowledge that I have received the following incentive item from BCFS HSS ConnectEd:
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Workshop Stipend GC
Enrollment and Entry Survey - Gift Card $25
Exit Survey Completion - Gift Card $10
Advocacy Incentive GC
Event Gift Card
By signing below, I Acknowledge that gift cards will not be used to purchase tobacco, alcohol, or firearms; transferred by to any other party; or redeemable for cash.
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Date
*
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Month
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Day
Year
Date
Submit
Should be Empty: