Alzheimer's Association

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Delaware Valley Chapter Change Location

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User Information
* User ID: Select a User ID from 5 - 30 characters in length. You may use letters, numbers, and underscores.
* Password: Select a password from 5-20 characters in length. Please use only letters and numbers.
* Re-type Password:  
Personal Information
* First Name: Please enter your first and last name.
* Last Name:
* Address 1: Please enter your billing address.
Address 2:
* City:
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* Email:
* Phone:
Honoree Information
Photo of honoree (200x200):
* First Name:    MI:
* Last Name:
* Short Message:
Donation and Payment Information
Type of Donation:
* Amount ($): The minimum donation to post a message on the living Flame page is $50 ($75 with a photo).
* Payment: By Credit Card
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The DVC will contact you to make other payment arrangements.
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Tribute Notification
List of Emails:
Please designate the individual(s) to be notified of your gift via email. Use a comma to separate emails.
Address 1: Please provide with address/phone information if email is not available.
Address 2:
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Relationship: Your relation to the donor.
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Chapter Headquarters
Delaware Valley - 399 Market Street, Suite 102,
Philadelphia, PA 19106 Phone 215.561.2919

National Headquarters
Alzheimer's Association National Office 225 N. Michigan Ave., Fl. 17, Chicago, IL 60601
© 2007 Alzheimer's Association. All rights reserved.

24/7 Helpline: 1.800.272.3900