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Gift Card Acknowledgement Form
BCFS Health and Human ServicesHealth and Human Services Est. 1944
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Age
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Card Information #
Select Facilitator OR Advocate who handed the card.
*
Please Select
Carolyn
Perry
Marleen
Elizabeth
Ema A.
Kristi J.
Karli
Krystal
Cell Phone
*
I acknowledge that I have received the following incentive item from BCFS HSS ConnectEd:
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Entry Survey - Gift Card $25
Exit Survey Completion - Gift Card $10
Workshop Stipend GC
Advocacy Stipend GC
YTIA School Supplies Bag
Other
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
-
Day
Year
Date
Submit
Should be Empty: