Thank you for your support.
Please print, complete, and mail this form with your cheque or credit card information to the address below.

For your convenience, we've also included the mailable form below. Asterisk indicates required information.  

* Required (for credit card contributions) -- name must match credit card information

Title ________ 
First Name* ________________
Last Name* _________________

Address* _________________________________

_________________________________________

Country _______________

E-mail* ________________

I am making a gift of:   

[ ] €25    [ ] €50    [ ] €100    [ ] €250    [ ] €500    [ ] Other €_______________

Make check payable to Western Alzheimers. To make your gift by credit card, fill out the information below:

Name (as it appears on card) __________________________________________

Credit Card Number __________________________________________

Expiration Date __________ (MM/YY)

This contribution is in honor/memory of _____________________________

Credit Card (circle one): MasterCard | VISA | Laser Card

I authorize Western Alzheimers to charge my credit card for the amount indicated above.

Signature ________________________________

This gift is: _____ in honor of   _____ in memory of

Name ___________________________________

Send card to:

Name & Address ___________________________

________________________________________

________________________________________

Please complete this form and mail it, along with your donation, to:

Western Alzheimers, Main Street, Ballindine, Co. Mayo

Leaving a Legacy

Remember the heart-stopping moment you learned a loved one or someone else you know had Alzheimer’s Disease? And how you wished you could help? Here’s one way you can. You can help us in our quest for new treatments, to improve quality of life for those affected by this unpredictable disease, and provide hope for a cure through the promise of research.

By Making a Donation, You Will Enjoy Many Rewards

Besides the personal joy of knowing you have contributed to the well-being of others, you will receive special acknowledgement. Your donation will ensure the continuation of our important work,  to help ease the burden to those carers caring for loved ones who suffer  the devastating effects of Alzheimer’s Disease.

If you request to remain anonymous, your gift will be kept completely confidential. However, recognition of your gift might encourage others to do the same. Whatever you request, we will honor your wishes because we appreciate your support immensely.

Interested in making a charitable contribution to

Western Alzheimers in lieu of favours for your special occasion?

Charitable contributions are becoming an increasingly popular alternative to favors for weddings, anniversaries, birthdays, and other special occasions. Many generous supporters of Western Alzheimers have chosen to make a charitable contribution as a way to honor or memorialize loved ones on their special day.