Mammogram Raffle Form
By filling out this form and providing proof of a future or recent mammogram appointment, you have a chance to win a variety of prizes from local stores. 4 winners will receive an email letting them know they have won. The total of 4 raffle prizes include a $25 Food Basics/Metro gift card, a $50 Vince's Market gift card, and 2x $50 value Farm Boy gift baskets. The goal is to improve knowledge and participation in breast cancer screenings to work our way towards better health for our community. No personal information will be shared or saved and will only be used to send prizes to winners. Additional submissions will not be entered into the raffle after February 19, 2025.
E-mail
example@example.com
Upload a photo to provide proof of a mammogram appointment within a 2 year range (within the past 2 years, or in the upcoming 2 years)
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Proof includes screenshots of booked appointments or an image of an appointment slip.
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Is this your first mammogram appointment?
Yes
No
Did this raffle encourage you to book an appointment?
Yes, I booked my first mammogram
Yes, I have not booked a mammogram in a long time
Yes, I forgot to but the raffle reminded me
No
Did the brochure for the raffle help you learn about breast cancer screenings?
Yes
No, I did not read the brochure
No, I already knew the information
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