Mail-in Donation Form

Thanks for supporting me as I participate in the
Walk ALS Hartford 2024
Participant Name: Lisa Pickman
Participant ID: 1034166

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: ALS United Connecticut
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:

ALS United Connecticut

Attn: Walk ALS Hartford 2024
4 Oxford Road
Suite E4
Milford, CT 06460

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 United Connecticut