Thank you for your contribution to the UCLA Alzheimer’s and Dementia Care Program. Your gift will support the Program’s mission to help patients and their families with the complex medical, behavioral and social needs of Alzheimer’s disease and other types of dementia.

Required fields are indicated with an asterisk (*).
Thank you for your contribution to the UCLA Alzheimer’s and Dementia Care Program
*I would like to make:
   Other $  
(Contributions of $1000 or more are eligible.)

* First name:  
  Middle name:
* Last name:  
   I am making this gift as a proxy for my organization/company, which should be recognized as the legal donor
  Company/Orgnization name:  
UCLA graduation year(s):  

  UCLA graduation year(s):

Joint Gift
* This is a joint gift with
my spouse/partner

Contact Information
* Street:  
U.S. Addresses  
*   City, State, Zip:
Non-U.S. Addresses  
  Non-U.S. City/County
  or Province/Postal Code:
* This address is my:  
* Home telephone:    
Business telephone:  

* E-mail address:  
* This e-mail is my:  

Matching Gift

  My/my spouse's employer will match my gift.
  Company name for matching gifts:
  This company is:
Tribute Gift
Please check this box if you would like to honor a family member, faculty member, business associate, community leader, or other with your contribution.
Please list the name of the honoree in the comments box below and let us know if your gift is in honor or in memory of this person. Also, please supply the name and address of any individual you wish to be notified of this gift.
Payment method:
I am interested in learning more about how I can include UCLA in my estate plan
This gift is anonymous
I am interested in learning more about the UCLA Division of Geriatrics.
One of the ways we express our gratitude is by listing our donors' names in UCLA honor rolls. If you wish to exclude your name, please check this box.