Thank you for supporting me with a gift to my fund:
Do-It-Yourself Fundraiser

Fund Creator: Holly Miller
Fund ID: 1011561
Fund Name: Testing Testing 123

Step 1. Billing Information

First Name:   Last Name:  
Address:  
City:   State:   Zip:  
Phone:   Email:  

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: ALS Northwest
Credit card #:   exp:   Signature: 
Recognition Name (ex: The Smith Family or Aunt Sue):  
Please provide the name of the person this is in honor of or in memorial for:
 
Please provide the name and contact information for those who should be notified about your tribute gift (email or mailing address):
 

Step 3.

Send this form with your donation to:
ALS Northwest
825 NE Multnomah St. - #940
Attn: Do-It-Yourself Fundraiser
Portland, OR 97232

For Office Use Only:

Check #   Cash $  
Received by   Entered in LO by  

If you have questions or to donate by phone, please call (503)-238-5559. | alsoregon.org
ALS Northwest