Brick/Paver Form

Thank you for your interest in purchasing Dine Out For Safety Raffle Tickets.

Ticket prices are as follows:

1 ticket: $10

3 tickets: $25

7 tickets: $50

15 tickets: $100

Use the form below to securely purchase your raffle tickets online. Once your payment has been processed, Dine Out For Safety Event Staff will add your contact information to the raffle ticket stub(s) to retain for the drawing. We will mail you the top of the ticket(s) for your records.

Please note: Raffle ticket purchases are not tax-deductible. All credit card transactions are processed through a secure portal.

If you have any questions, please contact Kristine Welter Hall via email at [email protected].

* Required Fields

Dine Out For Safety Raffle Tickets
Select Number of Raffle Tickets

Contact Information
* First Name
* Last Name
Company Name
* Address
Address 2
* City
* State/Province
* Zip/Postal Code
Phone
* Email
Comments

Help Us Cover Costs
Simply leave "Yes!" checked below to ensure that 100% of your intended donation is available for our mission.
Yes! I want $100.00 to go to CODAC Behavioral Health Services and I will donate $103.00. No. I will donate $100.00 and CODAC Behavioral Health Services will cover the processing costs.

Credit Card Information
Card Holder Name

Card Account Number
Expiration Date
* Security Code The 3 or 4 digit Security Code (CVV2) can be found on the back of your credit card. For American Express, the Security Code (CID) can be found on the front of the card.

Billing Address
Same As Above
* Address
City
State/Province
* Zip/Postal Code
Email

Privacy Policy
We keep your personal information private and secure. When you make a payment through our site, you provide your name, contact information, payment information, and additional information related to your transaction. We use this information to process your payment and to ensure your payment is correctly credited to your account.