CENSUS 2020 $100 DRAWING ENTRY FORM
One drawing per person/household. Must have a disability and be 18 years old to enter. 3 winners will receive a $100 Walmart Gift Card.
Name
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First Name
Last Name
Email
*
example@example.com
I am over 18 years old
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YES
NO
I understand that by submitting this photo I give disAbility Connections my permission to use my photo submission with no other identifying information on their social media sites to promote registration for the 2020 Census. disAbility Connections will not use my information for any other purpose and will not share my info with other entities. I have read and understand this information.
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YES
NO
Download your JPG or PDF "selfie" with your Census registration here:
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