Memory Walk Sponsor Pledge Form

Please print this form, fill-in the relevant pledge information and mail, fax or deliver it to the Chapter at the address found at the bottom of this document. All money and this form must be received by the Northern Virginia Chapter on or before October 30 to make you eligible for a grand prize. Money received after October 30 will not guarantee incentive prizes. Items will be mailed, delivered, or can be picked-up at the Chapter office: date is to be announced.

Name:

Team Name:

Home Telephone Number:     Work Telephone Number:
()           ()

Walk Site:

Sponsor Name Flat Pledge/By Mile Collected
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

Total Pledged: $

Total Collected: $  plus  Matching Gift: $ =

Final Total Enclosed: $

Send all information to:

Memory Walk
Alzheimer's Association, Northern Virginia Chapter
10201 Lee Highway, Suite 210
Fairfax, VA 22030
(FAX) 703/359-4441

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Last updated: April 9, 1999

Please return to https://www.alz-nova.org or
call 800-207-8679 or 703-359-4440
for more information.

© 1997, 1998 & 1999 Alzheimer's Association, Northern Virginia Chapter. All rights reserved.

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