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Donation Form

Donor Information
First Name: _____________________________ Last Name: ____________________________________
Billing Address: ________________________________________________________________________
City: ____________________________________________ State: ______________ Zip: _____________
Phone number: _________________________ Email Address*: _________________________________

*Email address will be used only to send donation receipt.

Donation Information
I would like to make a donation in the amount of:
__$1000 __$500 __$250 __$120 __$60 __$35 __Other Amount: $___________

Payment Method
___ Enclosed is my check payable to the Alzheimers Association
-ORPlease charge my: ____Visa ____MasterCard ____American Express
Credit card number: _____________________________________________________________________
Expiration date: ___________________
Signature: ____________________________________________________________________________
Todays date: _____________________

Participant Information (donation on behalf of)

Event Name: San Jose Walk to End Alzheimers
Participants Name: Jim and Linda Marken
Participants ID: 6575718
Team Name: Hazels Happy Memories
Company Name: Staff Team Plaques
Mail this form and contribution to:
San Jose Walk to End Alzheimers
31915 Rancho California Road #200-438
Temecula, CA 92591

Thank you for your contribution!