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
*
Card Information #
Select Facilitator OR Advocate who handed the card.
*
Please Select
Alejandra S.
Andrea J.
April S.
Ema A.
Lisa B.
Mahayla S.
Christiana W.
Kristi J.
Victoria L.
Alexa S.
Cell Phone
*
I acknowledge that I have received the following incentive item from BCFS HSS ConnectEd:
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Enrollment and Entry Survey - Gift Card $25
Exit Survey Completion - Gift Card $10
Completion of Phase 1 & 2 - Gift Card
Signature
*
Clear
Date
*
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Month
-
Day
Year
Date
Submit
Should be Empty: