Thank you for supporting me as I participate in
2023 Kern County Walk to Defeat ALS

Participant Name: Lance McCullah
Participant ID: 1010149
Team Name: Lance's Legions

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: The ALS Association Golden West Chapter
Credit card #:   exp:   /  

Signature:  
Name for Donor Honor Roll Recognition (ex: The Smith Family or Aunt Sue):  
Yes, this is an honor or memorial gift in honor of:
 
Please provide the name and contact information for those who should be notified about your tribute gift (email or mailing address):
   

Step 3. Mail it in

Send this form with your donation to:
The ALS Association Golden West Chapter
Attn: 2023 Kern County Walk to Defeat ALS
PO Box 7082
Woodland Hills, CA 91365

For Office Use Only:

Check #   Cash $  
Received by   Entered in LO by  

If you have questions or to donate by phone, please call (818)-865-8067. | alsagoldenwest.org
The ALS Association Golden West Chapter