Colorado Adventure Raffle Entry Form

Please complete the form below and click submit. Once your information is received, a Krist Samaritan Center representative will fill out a raffle ticket(s) and mail the other side of the ticket(s) to you for your reference when the raffle drawing is held on November 1, 2011, at A Samaritan Celebration.

Thank you and good luck!

First Name*:

Last Name*:

Number of Tickets*:

Street Address*:

Street Address:

City*:

State*:

Zip Code*:

Country:

Daytime Phone*:

Email Address*:

* Required Fields

You will be redirected to a secure site for payment processing.