Skip to content
AI WELLNESS RAFFLE ENTRY
RAFFLE ENTRY FORM
PARTICIPANT INFORMATION
Name
*
Name
First Name
First Name
Last Name
Last Name
Email
*
Phone
*
Address
*
Address
Street Address
Street Address
Apartment/Unit Number
Apartment/Unit Number
City
City
State/Province
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
SELECT YOUR DONATION
Support Type
*
Community Support Entry — $100 (Includes 1 Wellness Giveaway Entry)
Wellness Support Entry — $200 (Includes 3 Wellness Giveaway Entries)
• Complimentary Relax & Recharge Massage Experience
VIP Impact Entry — $300 (Includes 5 Wellness Giveaway Entries)
• Complimentary Relax & Recharge Massage Experience
• Complimentary Skin & Scalp Treatment Experience
Platinum Impact Entry — $500 (Includes 10 Wellness Giveaway Entries)
• Complimentary Relax & Recharge Massage Experience
• Complimentary Skin & Scalp Treatment Experience
• Complimentary Biohacking Experience at AI Wellness Center of Excellence
Quantity
*
Total
ACKNOWLEDGEMENT
By signing below, I acknowledge that:
I understand that all raffle proceeds benefit the Medical Mission in Philippines; I agree that photos and videos from the event may be used for promotional and media purposes.
Signature
*
signature
keyboard
Clear
Payment Method
*
Pay Now
Payment
*
Submit
If you are human, leave this field blank.