Copy of Allegany County CHA Survey 2022

2022 Allegany County Community Health Survey

On behalf of the Allegany County Department of Health, Cuba Memorial Hospital, Jones Memorial Hospital and the Community Wellness Committee of Allegany County; thank you for participating in the 2022 Community Health Assessment Survey.

The following survey is only for adults 18 years of age and older. It is an opportunity for you to voice your opinion about our community’s health and wellness. As well, health care leaders will gain knowledge about our current health care system, learn important information about our community’s health status, and find new ways to support our community in becoming the healthiest county in New York State. We encourage all Allegany County residents to participate.

To thank you for your participation you will be entered into a drawing for a chance to win one of six (6) $50 gas gift certificates or one of eight (8) $25 gas gift certificates. Upon completion of the survey, you will be directed to a separate page to add your contact information for a chance to win one of these prizes.

We appreciate your help. Surveys must be completed and received via the on-line survey or by mail no later than Thursday, June 30th, 2022. Please mail your survey to: Attention: Theresa Moore, Allegany County Department of Health, County Office Building, Room 30, 7 Court Street, Belmont NY 14813.

Question Title

* 1. Do you have any kind of health care coverage or health insurance? (check one)

Yes

Used to, but don't have any now

Don't Know

Question Title

* 2. How do you pay for your Health Care? (Check all that apply)

I have health insurance through my employer

I have Medicare

I have Medicaid

I am covered by the VA

I purchased health insurance through NYS of Health/Marketplace Exchange

I use Tribal Health

I pay cash

Question Title

* 3. Where do you get most of your health information? (select up to three (3) choices)

Doctor/Medical Provider/Primary Care Provider

Library

Newspaper or Magazine

School Nurse/School Health Educator/Teacher

Computer or Internet

Social Media (Facebook, Twitter, etc.)

Television (TV) or Radio

Friends and Family

Health Insurance Company

Social Services

Head Start

WIC (Nutrition program for children and pregnant/nursing women)

Work Place

Community Health Worker/Peer Navigator

Question Title

* 4. How often do you see your primary care provider (doctor)? (check one)

Several times a year

For a yearly check-up

Only when I'm sick

I don't go see my primary care provider

I don't have a primary care provider

Question Title

* 5. In the past year, was there any time that you needed medical care but could not - or did not get it?

Yes

If yes, how many times?

Question Title

* 6. What are the main reasons you did not get the medical care you needed? Choose all that apply.

Cost - without insurance, it was too expensive

Cost - even with insurance, it was too expensive

Transportation - it was too hard to get there

Hours - they weren't open when I could get there

I couldn't get time off from work

I had no one to watch my children

I couldn't get an appointment for a long time

The medical staff didn't speak my language

I couldn't get a referral to see a specialist

I didn't know where to get the care I needed

I decided not to go because I don't like going to doctors

Other (please specify)

Question Title

* 7. In the past year, was there any time that you needed mental health care but could not - or did not get it?

Yes

If yes, how many times?

Question Title

* 8. In the past year, was there any time that you or your children needed dental care but could not - or did not get it?

Yes

If yes, how many times?

Question Title

* 9. How often do you participate in physical activity or exercise? (check one)

5-7 times per week for at least 30 minutes each time

2-4 times per week for at least 30 minutes each time

0-1 times per week for at least 30 minutes each time

I don't exercise regularly, but try to add physical activity when possible

No physical activity or exercise beyond regular daily activities

Question Title

* 10. Which, if any of the following would help you become more active? (check all that apply)

Transportation to park

Groups to participate

Workshops for classes about exercise

Safe place to walk or exercise

Individual instruction/personal trainer

Information about exercise programs or gym memberships

Discounts for exercise programs or gym memberships

Workplace programs or equipment

A friend to exercise with

Activities you can do with your children

None of the above

Other (please specify)

Question Title

* 11. Have you ever been told by a doctor or a nurse, that you had any of the following? (check all that apply)

Blood sugar problems or diabetes

Heart related issues (high blood pressure, heart disease, or stroke)

High cholesterol

Cancer

Extreme overweight or obesity

Asthma, COPD or other breathing issues

Mental health/depression/anxiety

None of the above

Other (please specify)

Question Title

* 12. If you are living with a chronic illness, what do you do to manage your diseases? (check all that apply)

Take medications as prescribed by my healthcare provider

Take over-the-counter medications

Exercise

Proper nutrition

Attend educational workshops to learn about my disease

Attend counseling

Participate in a self-help program (support groups, etc.)

I do not do anything specific to manage my disease

See alternative/holistic care (massage, acupuncture, reiki, medication, homeopathy, art therapy, etc.)

Take illegal drugs

Other (please specify)

Question Title

* 13. Which of the following do you know how to find in Allegany County? (check all that apply)

To dispose of unused prescription drugs

Diabetes testing

Blood pressure testing

Cholesterol testing

Cancer screening

Nutrition education

Depression/mental health issues

Family planning services/reproductive health

HIV/sexually transmitted infection testing and treatment

Alternative/holistic care (massage, acupuncture, etc.)

Creative activities and events (arts, music, etc.)

Other (please specify)

Question Title

* 14. What services do you leave the county for? (check all that apply)

To dispose of unused prescription drugs

Blood pressure testing

Diabetes testing

Cholesterol testing

Cancer screening

Nutrition education

Depression/mental health issues

Family planning services/reproductive health

HIV/sexually transmitted infection testing and treatment

Substance use/treatment services

Alternative/holistic care (massage, acupuncture, etc.)

Creative activities and events (arts, music, etc.)

I do not leave the county for any of these

Other (please specify)

Question Title

* 15. What is the main reason(s) for traveling outside of your county for these services? (check all that apply)

To get better quality care

The healthcare provider is closer to my home/work

No healthcare provider in my county

Cannot get an appointment/long wait

Insurance not accepted

Other (please specify)

Question Title

* 16. In the past 30 days, have you used any of the following nicotine products? (check all that apply)

Cigarettes (Marlboro, Camel, Newport, Pall Mall, Winston, Seneca, etc)

Electronic cigarettes (Vape Pens, Blu, Juul, Mods, Tanks)

Smokeless tobacco (chewing tobacco, snuff, snus, etc.)

Cigars, Cigarillos, Little Cigars

Pipes

Hookah/water pipe

I do not smoke or use nicotine products

Other (please specify)

Question Title

* 17. Check all that apply

I would like to quit

I would like to reduce the amount I smoke

I have tried to quit

I use e-cigs to quit

I do not want to quit

Not applicable

Question Title

* 18. Legal purchase age for tobacco products and e-cigarettes in New York is now 21.

No responses needed

Question Title

* 19. In the past 30 days, have you drank any alcohol? (beer, wine, liquor, etc.)

Yes

Question Title

* 20. How many servings of alcohol (beer, wine, liquor, etc.) do you drink in a week? (check one)

0-3 servings of beer, wine or liquor in a week

4-7 servings of beer, wine or liquor in a week

8-11 servings of beer, wine or liquor in a week

12-14 servings of beer, wine or liquor in a week

More than 14 servings of beer, wine or liquor in a week

Question Title

* 21. During the past 30 days, what drugs have you used recreationally? (not prescribed by a doctor) (check all that apply)

Anxiety medication (Xanax, Ativan, etc.)

Prescription medications

Methamphetamine

Marijuana

Heroin/fentanyl

Opioids

Cocaine

I do not use drugs recreationally

Question Title

* 22. What are your drinks of choice on most days? Check all that apply

Water

Milk

Pop or soda

Diet pop or diet soda

Coffee (hot or iced)

Coffee (hot or iced) with added sugar, creamer, flavorings, etc.

Tea (hot or iced)

Tea (hot or iced) with sugar, creamer, flavorings, etc.

100% juice

Juice drinks

Energy drinks (Monster, Amp, Red Bull, etc.)

Sports drinks (Gatorade, Powerade, etc.)

Kool-Aid, Crystal Light, other drink mixes

Question Title

* 23. During the past 7 days, how many times did you drink a bottle or glass of water? Count tap, bottle and unflavored sparkling water. (check one)

I did not drink water during the past 7 days

1-3 times during the past 7 days

4-6 times in the past 7 days

1 time per day

2 times per day

3 times per day

4 times per day

Question Title

* 24. During the past 7 days, how many times did you eat fruit? (do not count fruit juice) (a serving is 1 cup or a fist size) (check one)

I did not eat fruit in the past 7 days

1-3 times during the past 7 days

4-6 times during the past 7 days

1 time per day

2 times per day

3 times per day

4 or more times per day

Question Title

* 25. What keeps you from eating more fruits every day? (check all that apply)

Time it takes to prepare

Cost

The stores near me don't sell fresh fruits

I don't like to eat healthy food

My family does not like to eat healthy

I am not sure how to cook/prepare fresh fruits

Question Title

* 26. During the past 7 days, how many times did you eat vegetables? (do not count vegetable juice) (a serving is 1 cup or a fist sized piece) (check one)

I did not eat vegetables during the past 7 days

1-3 times during the past 7 days

4-6 times during the past 7 days

1 time per day

2 times per day

3 times per day

4 or more times per day

Question Title

* 27. What keeps you from eating more vegetables every day? (check all that apply)

Time it takes to prepare

Cost

The stores near me don't sell fresh vegetables

I don't like to eat healthy food

My family does not like to eat healthy

I am not sure how to cook/prepare fresh vegetables

Question Title

* 28. On average, how many days in a week do you eat out or purchase prepared food? (fast food, deli food, sub shop, pizza, etc.) (check one)

Everyday

4-6 days a week

1-3 days a week

No days

Question Title

* 29. Which of these is the biggest challenge or barrier keeping you from eating healthy foods? (no sugar added, preservative-free grains, non-GMO foods and poultry, meat and dairy not treated with chemicals or hormones, etc.) (check one)

I don't enjoy the taste of healthy food

Buying healthy food is too expensive

I don't have any place nearby to buy healthy food

I don't have the transportation to go shopping for healthy food

I don't know how to cook and prepare healthy meals that taste good

I don't have the supplies and equipment I'd need to cook healthy food

The others in my household don't eat healthy and we eat together

I don't want or need to eat healthier than I already do

Food pantries do not have healthy food

I don't have the time to shop for and prepare healthy food

I really don't have any barriers keeping me from eating health food

Some other challenge or barrier (please specify)

Question Title

* 30. Studies and research show that the arts are necessary to human health and community wellness. Which creative arts activities do you use to support your overall wellness? (check all that apply)

Movies, television, video, film at home

Recorded music at home

Movies at my local theater

Live music

Books, literature and/or book groups

Theater and performing arts

Dance

Visual arts show and exhibits

I make my own art and/or craft projects

Attend craft shows

I write and/or participate in poetry and writers workshops in my community

I participate in community art groups and/or creative projects with other community members

N/A - I can't afford to use the arts to support my wellness

N/A - I am NOT interested in using the arts to support my wellness

Question Title

* 31. Have any of the following directly affected you or your family in the last 2 years? (consider things like coverage under your health benefit plan, cost of service, location, transportation, knowledge of providers, etc)

	Very Serious Affect	Serious Affect	Somewhat of an Affect	Small Affect	No Affect	Does Not Apply (N/A)
Access to insurance coverage	Access to insurance coverage Very Serious Affect	Access to insurance coverage Serious Affect	Access to insurance coverage Somewhat of an Affect	Access to insurance coverage Small Affect	Access to insurance coverage No Affect	Access to insurance coverage Does Not Apply (N/A)
Access to adult immunizations	Access to adult immunizations Very Serious Affect	Access to adult immunizations Serious Affect	Access to adult immunizations Somewhat of an Affect	Access to adult immunizations Small Affect	Access to adult immunizations No Affect	Access to adult immunizations Does Not Apply (N/A)
Access to childhood immunizations	Access to childhood immunizations Very Serious Affect	Access to childhood immunizations Serious Affect	Access to childhood immunizations Somewhat of an Affect	Access to childhood immunizations Small Affect	Access to childhood immunizations No Affect	Access to childhood immunizations Does Not Apply (N/A)
Access to general health screenings (blood pressure, cholesterol, colorectal cancer, diabetes	Access to general health screenings (blood pressure, cholesterol, colorectal cancer, diabetes Very Serious Affect	Access to general health screenings (blood pressure, cholesterol, colorectal cancer, diabetes Serious Affect	Access to general health screenings (blood pressure, cholesterol, colorectal cancer, diabetes Somewhat of an Affect	Access to general health screenings (blood pressure, cholesterol, colorectal cancer, diabetes Small Affect	Access to general health screenings (blood pressure, cholesterol, colorectal cancer, diabetes No Affect	Access to general health screenings (blood pressure, cholesterol, colorectal cancer, diabetes Does Not Apply (N/A)
Access to mental health care services	Access to mental health care services Very Serious Affect	Access to mental health care services Serious Affect	Access to mental health care services Somewhat of an Affect	Access to mental health care services Small Affect	Access to mental health care services No Affect	Access to mental health care services Does Not Apply (N/A)
Access to prenatal care	Access to prenatal care Very Serious Affect	Access to prenatal care Serious Affect	Access to prenatal care Somewhat of an Affect	Access to prenatal care Small Affect	Access to prenatal care No Affect	Access to prenatal care Does Not Apply (N/A)
Access to transportation to medical care providers and services	Access to transportation to medical care providers and services Very Serious Affect	Access to transportation to medical care providers and services Serious Affect	Access to transportation to medical care providers and services Somewhat of an Affect	Access to transportation to medical care providers and services Small Affect	Access to transportation to medical care providers and services No Affect	Access to transportation to medical care providers and services Does Not Apply (N/A)
Access to women's health services	Access to women's health services Very Serious Affect	Access to women's health services Serious Affect	Access to women's health services Somewhat of an Affect	Access to women's health services Small Affect	Access to women's health services No Affect	Access to women's health services Does Not Apply (N/A)
Access to primary medical care providers	Access to primary medical care providers Very Serious Affect	Access to primary medical care providers Serious Affect	Access to primary medical care providers Somewhat of an Affect	Access to primary medical care providers Small Affect	Access to primary medical care providers No Affect	Access to primary medical care providers Does Not Apply (N/A)
Availability of specialists/specialty medical care	Availability of specialists/specialty medical care Very Serious Affect	Availability of specialists/specialty medical care Serious Affect	Availability of specialists/specialty medical care Somewhat of an Affect	Availability of specialists/specialty medical care Small Affect	Availability of specialists/specialty medical care No Affect	Availability of specialists/specialty medical care Does Not Apply (N/A)
Access to affordable health care (related to copays and deductibles)	Access to affordable health care (related to copays and deductibles) Very Serious Affect	Access to affordable health care (related to copays and deductibles) Serious Affect	Access to affordable health care (related to copays and deductibles) Somewhat of an Affect	Access to affordable health care (related to copays and deductibles) Small Affect	Access to affordable health care (related to copays and deductibles) No Affect	Access to affordable health care (related to copays and deductibles) Does Not Apply (N/A)
Access to dementia care services	Access to dementia care services Very Serious Affect	Access to dementia care services Serious Affect	Access to dementia care services Somewhat of an Affect	Access to dementia care services Small Affect	Access to dementia care services No Affect	Access to dementia care services Does Not Apply (N/A)
Access to dental care	Access to dental care Very Serious Affect	Access to dental care Serious Affect	Access to dental care Somewhat of an Affect	Access to dental care Small Affect	Access to dental care No Affect	Access to dental care Does Not Apply (N/A)
Access to emergency shelter in the area	Access to emergency shelter in the area Very Serious Affect	Access to emergency shelter in the area Serious Affect	Access to emergency shelter in the area Somewhat of an Affect	Access to emergency shelter in the area Small Affect	Access to emergency shelter in the area No Affect	Access to emergency shelter in the area Does Not Apply (N/A)

Question Title

* 32. Have any of the following directly affected you or your family in the last 2 years?

	Very Serious Affect	Serious Affect	Somewhat of an Affect	Small Affect	No Affect	Does Not Apply (N/A)
Alcohol abuse	Alcohol abuse Very Serious Affect	Alcohol abuse Serious Affect	Alcohol abuse Somewhat of an Affect	Alcohol abuse Small Affect	Alcohol abuse No Affect	Alcohol abuse Does Not Apply (N/A)
Prescription drug abuse	Prescription drug abuse Very Serious Affect	Prescription drug abuse Serious Affect	Prescription drug abuse Somewhat of an Affect	Prescription drug abuse Small Affect	Prescription drug abuse No Affect	Prescription drug abuse Does Not Apply (N/A)
Illegal drug use	Illegal drug use Very Serious Affect	Illegal drug use Serious Affect	Illegal drug use Somewhat of an Affect	Illegal drug use Small Affect	Illegal drug use No Affect	Illegal drug use Does Not Apply (N/A)
Crime	Crime Very Serious Affect	Crime Serious Affect	Crime Somewhat of an Affect	Crime Small Affect	Crime No Affect	Crime Does Not Apply (N/A)
Delinquency/youth crime	Delinquency/youth crime Very Serious Affect	Delinquency/youth crime Serious Affect	Delinquency/youth crime Somewhat of an Affect	Delinquency/youth crime Small Affect	Delinquency/youth crime No Affect	Delinquency/youth crime Does Not Apply (N/A)
Domestic violence/abuse	Domestic violence/abuse Very Serious Affect	Domestic violence/abuse Serious Affect	Domestic violence/abuse Somewhat of an Affect	Domestic violence/abuse Small Affect	Domestic violence/abuse No Affect	Domestic violence/abuse Does Not Apply (N/A)
Sexual abuse	Sexual abuse Very Serious Affect	Sexual abuse Serious Affect	Sexual abuse Somewhat of an Affect	Sexual abuse Small Affect	Sexual abuse No Affect	Sexual abuse Does Not Apply (N/A)
Child physical abuse	Child physical abuse Very Serious Affect	Child physical abuse Serious Affect	Child physical abuse Somewhat of an Affect	Child physical abuse Small Affect	Child physical abuse No Affect	Child physical abuse Does Not Apply (N/A)
Child sexual abuse	Child sexual abuse Very Serious Affect	Child sexual abuse Serious Affect	Child sexual abuse Somewhat of an Affect	Child sexual abuse Small Affect	Child sexual abuse No Affect	Child sexual abuse Does Not Apply (N/A)
Child emotional abuse	Child emotional abuse Very Serious Affect	Child emotional abuse Serious Affect	Child emotional abuse Somewhat of an Affect	Child emotional abuse Small Affect	Child emotional abuse No Affect	Child emotional abuse Does Not Apply (N/A)
Child neglect	Child neglect Very Serious Affect	Child neglect Serious Affect	Child neglect Somewhat of an Affect	Child neglect Small Affect	Child neglect No Affect	Child neglect Does Not Apply (N/A)
Violence	Violence Very Serious Affect	Violence Serious Affect	Violence Somewhat of an Affect	Violence Small Affect	Violence No Affect	Violence Does Not Apply (N/A)
Gun violence	Gun violence Very Serious Affect	Gun violence Serious Affect	Gun violence Somewhat of an Affect	Gun violence Small Affect	Gun violence No Affect	Gun violence Does Not Apply (N/A)
Lack of exercise/physical activity	Lack of exercise/physical activity Very Serious Affect	Lack of exercise/physical activity Serious Affect	Lack of exercise/physical activity Somewhat of an Affect	Lack of exercise/physical activity Small Affect	Lack of exercise/physical activity No Affect	Lack of exercise/physical activity Does Not Apply (N/A)
Sexual behaviors (unprotected, irresponsible/risky)	Sexual behaviors (unprotected, irresponsible/risky) Very Serious Affect	Sexual behaviors (unprotected, irresponsible/risky) Serious Affect	Sexual behaviors (unprotected, irresponsible/risky) Somewhat of an Affect	Sexual behaviors (unprotected, irresponsible/risky) Small Affect	Sexual behaviors (unprotected, irresponsible/risky) No Affect	Sexual behaviors (unprotected, irresponsible/risky) Does Not Apply (N/A)
Teenage pregnancy	Teenage pregnancy Very Serious Affect	Teenage pregnancy Serious Affect	Teenage pregnancy Somewhat of an Affect	Teenage pregnancy Small Affect	Teenage pregnancy No Affect	Teenage pregnancy Does Not Apply (N/A)
Tobacco use	Tobacco use Very Serious Affect	Tobacco use Serious Affect	Tobacco use Somewhat of an Affect	Tobacco use Small Affect	Tobacco use No Affect	Tobacco use Does Not Apply (N/A)
Tobacco use during pregnancy	Tobacco use during pregnancy Very Serious Affect	Tobacco use during pregnancy Serious Affect	Tobacco use during pregnancy Somewhat of an Affect	Tobacco use during pregnancy Small Affect	Tobacco use during pregnancy No Affect	Tobacco use during pregnancy Does Not Apply (N/A)
Driving under the influence of drugs or alcohol	Driving under the influence of drugs or alcohol Very Serious Affect	Driving under the influence of drugs or alcohol Serious Affect	Driving under the influence of drugs or alcohol Somewhat of an Affect	Driving under the influence of drugs or alcohol Small Affect	Driving under the influence of drugs or alcohol No Affect	Driving under the influence of drugs or alcohol Does Not Apply (N/A)
Texting and driving	Texting and driving Very Serious Affect	Texting and driving Serious Affect	Texting and driving Somewhat of an Affect	Texting and driving Small Affect	Texting and driving No Affect	Texting and driving Does Not Apply (N/A)
Motor vehicle crash deaths	Motor vehicle crash deaths Very Serious Affect	Motor vehicle crash deaths Serious Affect	Motor vehicle crash deaths Somewhat of an Affect	Motor vehicle crash deaths Small Affect	Motor vehicle crash deaths No Affect	Motor vehicle crash deaths Does Not Apply (N/A)
Gambling	Gambling Very Serious Affect	Gambling Serious Affect	Gambling Somewhat of an Affect	Gambling Small Affect	Gambling No Affect	Gambling Does Not Apply (N/A)
Suicide	Suicide Very Serious Affect	Suicide Serious Affect	Suicide Somewhat of an Affect	Suicide Small Affect	Suicide No Affect	Suicide Does Not Apply (N/A)
Mental health issues (depression, anxiety, etc.)	Mental health issues (depression, anxiety, etc.) Very Serious Affect	Mental health issues (depression, anxiety, etc.) Serious Affect	Mental health issues (depression, anxiety, etc.) Somewhat of an Affect	Mental health issues (depression, anxiety, etc.) Small Affect	Mental health issues (depression, anxiety, etc.) No Affect	Mental health issues (depression, anxiety, etc.) Does Not Apply (N/A)

Question Title

* 33. In the future, what might help you make healthy changes in your life? (please select three (3))

Access to free workshops/classes in your community on exercise, diet, stress reduction, chronic disease management and/or quitting smoking

Being part of a support group that supports and encourages healthy habits

Getting more information from social media, internet, newspaper and TV

Getting reminders when you are due for certain tests (such as annual doctor visits)

Having more trust or comfort with the medical system

Having safe areas to exercise within your community

Having more affordable fresh fruits and vegetables or more healthy food choices at local convenience stores

Having the desire for me and my family to be healthier

Local hospitals and business offering free health screenings (blood pressure, etc.)

More recreational/sports opportunities that are appropriate to your age and skill level

Taking more time to talk with healthcare professionals (doctors, nurses, counselors, etc.)

Transportation

Other (please specify)

Question Title

* 34. What category best describes your race? (check all that apply)

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Don't Know

Other (please specify)

Question Title

* 35. What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

Question Title

* 36. What is your gender?

Female

Male

Transgender

Do not identify

Question Title

* 37. What is your employment status? (check one)

Currently employed for wages

Self-employed

Out of work for less than one year

Out of work for more than one year

Homemaker

Student

Retired

Unable to work

Part-time employment

Other (please specify)

Question Title

* 38. During the past 12 months, what was your total household income before taxes? (check one)

Under $14,999

$15,000 to $24,999

$25,000 and $49,999

$50,000 and $74,999

$75,000 and $99,999

Over $100,000

Question Title

* 39. During the past 12 months, how many people lived in your home, including yourself? Please enter the number for each age group and the total.

Number of children (age 17 and under)

Number of adults (age 18 to 64)

Number of adults (age 65 and over)

Total number in your household

Question Title

* 40. Are you an Allegany County resident or a student attending college in Allegany County??

Yes

Yes (college student)

Question Title

* 41. What is your zip code?

Question Title

* 42. On behalf of the Allegany County Department of Health, Cuba Memorial Hospital, Jones Memorial Hospital, and the Community Wellness Committee of Allegany County, thank you for participating in the 2022 Community Health Assessment Survey.

To thank you for your participation, you will be entered into a drawing for a chance to win one of six (6) $50 gas gift certificates or one of eight (8) $25 gas gift certificates.

Please complete the information below to be entered into drawings for the gas gift certificates.

Name

Email Address

Phone Number