ALS Association
The Marc West Fund

Gift Information

Donor Name (ex: The Smith Family or Bob and Sue Smith):  

$500 $250 $100 $50 $25 Other $ 

One-time Gift Recurring Gift | Frequency   | Total Amount  

This gift is in HONOR / MEMORY (circle one) of:  

A blank notecard will be provided to you with your receipt/acknowledgement if you'd like to notify the honoree or their family

Billing Information

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

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

Gift Information

Check #  , made payable to: The ALS Association | Total Included: $  
Credit card #:   exp:   /  

Total Included $:   Signature:  

Please only attach one donation per form. Send this form with your donation to:

The ALS Association Evergreen Chapter

Attn: Community of Hope
19717 62nd Ave S., D101
Kent, WA 98032