Mail-in Donation Form

Thank you for supporting me as I participate in the
Walk to Defeat ALS Winston-Salem
Participant Name: Jim Whitehead
Participant ID: 7297489
Team Name: Hap's Heroes

Step 1. Print Billing Information

First Name:   Last Name:  
Address:  
City:   State:   Zip:  
Phone:   Email (optional):  

Address is different than one on check. Please use above address.

Step 2. Select Donation Details

$500 $250 $100 $50 $25 Other $ 

Cash
Check #  , made payable to: The ALS Association
Credit card #:   exp:   /  

Signature:  
Name for Participant's Donation Scroll (ex: The Smith Family or Aunt Sue):  

Step 3. Mail it in

Please only attach one donation per form and always use a security envelope. Send this form with your donation to:

The ALS Association Gerald Talley - North Carolina Chapter

Attn: Walk to Defeat ALS
4 North Blount Street
Suite 200
Raleigh, NC 27601

Please note that it may take up to 2 weeks to post your donation online.

For Office Use Only:

Check #   Cash $  
Received by   Entered in Luminate by  
ALS Association