"Lou Gehrig's Disease"
800.882.5764
24359 Northwestern Hwy., Suite 100
Southfield, MI  48075   Contact Us
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For 39 years, helping people with ALS (pALS), their families,
and caregivers to live life as fully as possible
Click here to Donate Now!

"Never Give Up"  Bracelets Order Form

Yes!  I'd like to help support ALS of Michigan!
Please send me the indicated number of bracelets:
* required field
Note: If paying by credit card, the name and address must match that shown on your card.
*Name: 

**Please note there is a $5.00 minimum per order and $10.00 minimum for credit card orders**
** We must charge a minimum of $4.00 for shipping and handling**
Order Quantity
*No. Bracelets:     
Bracelet Cost:       @$1.00 ea.
Shipping:       @$4.00 / 50
Total:     
*Address1: 
Address2: 
*City: 
*State: 
*Zip: 
*Phone: 
Fax: 
*Email: 
*Confirm Email: 
Payment Preference *(choose one)
  Check will be mailed - Please make payable to ALS of Michigan Inc. and mail to:
ALS of Michigan, Inc.
24359 Northwestern Hwy., Ste 100
Southfield, MI 48075
  I prefer to pay with my credit card (you will add your card information on the next page):

  

We accept American Express, Discover, MasterCard and Visa credit cards.

For more information email Judi Fortuna or call her at 800-882-5764 ext. 224.