Support me as I participate in the  7th Annual ADRC Golf Classic
Participant’s Name:
Participant’s ID:
Team Name:
   
  Yes! I will make a contribution to help Alzheimer's Disease Resource Center
   
  $120 $60 $35 Other Amount: ______________________
 
Please Make Your Checks Payable to: Alzheimer's Disease Resource Center
   
Name: ___________________________________________________________________
   
Address: ___________________________________________________________________
       
City: ___________________________ State/Province: ___________________________
   
Zip/Postal Code: ___________________________
   
Country: __________________________
   
Donor Phone: _________________________________________________
   
Email: _________________________________________________________
 
 

Thank You So Much For Your Contribution!

Please Mail this form and check to:

Alzheimer's Disease Resource Center
Mary Ann Malack-Ragona
45 Park Ave.
Bay Shore NY 11706