Survey - 2023 RUNNING BITCOIN CHALLENGE DONATION INFORMATION - The ALS Association Golden West Chapter

2023 RUNNING BITCOIN CHALLENGE DONATION INFORMATION

PLEASE DONATE USING THE DONATE BTC BUTTON BELOW. First please fill in the information requested, so we can properly credit the participant and acknowledge you. Then, please proceed to the DONATE BTC button below. Thank you for making a generous gift in support of the 2023 Running Bitcoin Challenge!!

1. Donor Name and Information for Recognition (All fields optional except email address.)

First

Last

Professional Suffix

Street 1:

Street 2:

City/Town:

State / Province:

ZIP:

Country:

Field Is Required Email:

Phone Number:

Yes, I would like to receive important updates about this event from the Golden West Chapter.

Yes, I would like to receive postal mail from The ALS Association Golden West Chapter

2. I am a registered participant in the Running Bitcoin Challenge.

3. Field Is Required In Honor Of/In Memory Of? Please make at least 1 selection from the choices below.

I am donating to a specific participant in this Challenge.
I am donating in honor of someone living with ALS.
I am donating in memory of someone lost to ALS.
I am just making a general donation in support of the cause.

4. If applicable, please name the participant and/or the honoree. If you are donating in honor of a registered Challenge participant, their fundraising page will be updated within a few business days to reflect this donation. (Maximum response 255 chars, approx. 5 rows of text)

5. Field Is Required Yes/No? I would like you to inform the participant of my donation.

6. Field Is Required Please note the amount you intend to donate through BTCPay Server (please use a number and identify BTC or sats). You will be asked to reconfirm this amount again when you make your payment.

7. Are there any additional instructions, requests, or comments you would like to include about this donation? (Maximum response 255 chars, approx. 5 rows of text)