Support me as I participate in the Memory Walk – Southern Oregon

Support me as I participate in the Memory Walk – Southern Oregon
To make an offline donation, please complete this form and mail it with your check to the address listed below. Participants, please use
this form when submitting your offline donations. We have disabled the offline pledge entry tool on your website.
Support me as I participate in the Memory Walk –
Southern Oregon ~ Medford
Participant’s Name: ____________________________
Team Name: __________________________________
General Walk Donation – No Team/Participant Credited
Yes! I will make a contribution of $_________to help the Alzheimer’s Association of Southern Oregon.
Please make your check payable to:
Alzheimer’s Association – Oregon Chapter
Name :______________________________________________________
Address: ____________________________________________________
City: _______________________ State: _________________
Zip: ______________
Phone: ______________________
Email: ______________________________________________________
Thank you so much for your contribution!
Mail this form and your check to:
Alzheimer’s Association
1650 NW Naito Parkway, Suite 190
Portland, OR 97209
Additional Information
Please fill out the donation form and mail it along with your donation to the above address. If you’d like to
make your donation in honor/memory of someone, please fill in the information below:
(Circle one) In Memory of/In Honor of: _______________________________
For Credit Card Donations:
Card Type (Circle One): Visa, MasterCard
Card #: ____________________________________________ Expiration Date: __________
Signature: __________________________________________ 3 Digit Security Code: _____
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