National Stroke Association

Honor Gift Type: Required Honor gift type is required. Choose the memorial gift only if the person you are honoring is deceased.

Honoree Title:

Honoree Name: Required Honoree name is required.

Select A Gift Amount: Required

$25 - to list my Champion on the tribute section of www.stroke.org.

$50 - to also send a letter to my honoree announcing my gift.

$100 - to add a picture to the website listing.

$200 - to add a listing in the annual report.

$500 - to add a listing in StrokeSmart(TM) magazine.

$1000 - to add a dedicated honoree webpage for one year.

Other Amount Enter amount.

Notification Recipient Name: Enter the name of the person that should be contacted regarding this gift.

Notification Recipient Street 1:

Notification Recipient Street 2:

Notification Recipient City:

Notification Recipient State/Province:

Notification Recipient ZIP/Postal Code:

Notification Recipient Country:

Donor Title:

Donor First Name: Required Donor first name is required.

Donor Last Name: Required Billing last name is required.

Donor Suffix:

Donor Street 1: Required Donor street address is required.

Donor Street 2:

Donor City: Required Donor city is required.

Donor State/Province: Required Donor state or province is required.

Donor ZIP/Postal Code: Required Donor zip or postal code is required.

Donor Country:

Donor Phone Number: Required Donor phone number is required.

Donor Email Address: Required An email address is required.

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If you donate and have not already registered, you will receive periodic updates and communications from National Stroke Association.

Joint Donor First Name:

Joint Donor Last Name:

Credit Card Type:

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Credit Card Number: Required Credit card number is required.

CVV Number: Required CVV number is required.

Select month of credit card Expiration Date: Required Select Expiration Year