DONATION FORM Donor Information First name ___________________________________________
Last name __________________________________________
Billing Address ________________________________________________________________________________________________ City ________________________________________________
q My shipping address is the same as my billing address Shipping Address ______________________________________________________________________________________________ City _______________________________________________
State _______________________
ZIP _____________________
Donation Information I would like to make a donation in the amount of:
q $1,000
q $500
q $250
q $120
q $60 q $35
o Other (Please list amount): $_______________________
q Enclosed is my cash donation. q Enclosed is my check payable to the Alzheimer’s Association®. q Yes, my company has a matching gift program. Please charge my q Visa q Mastercard q American Express
Participant Information (please complete as fully as possible) I am supporting (circle one): A. A specific Walk to End Alzheimer’s participant B. A specific team C. Walk to End Alzheimer’s through a general donation Participant’s first name ________________________________________
Last name _____________________________________
Team name�������������������������������������������������������������������������������������������������� Walk location (city, state)��������������������������������������������������������������������������������������
For Donor Services Use Only: Participant name ___________________________________________
Participant ID _________________________________
Team name ________________________________________________ Team ID ______________________________________ Event name ________________________________________________ Event ID ______________________________________ WALK_17_096
walk-donation-form.pdf
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