Printable Donation Form

Please print this form, fill it out, FAX or send along with your donation to:

Muscular Dystrophy Association – San Diego               Phone:  858.492.9792
8525 Gibbs Drive, Suite 304                                        FAX:    858.492.1282
San Diego, CA 92123

Payment Method:

  Enclosed is my check (payable to Muscular Dystrophy Association)
  Please charge my credit or debit card account using the information provided below.

I'm happy to make a tax-deductible contribution to MDA of:
 $__________    $500    $250    $100    $50    $25  

 American Express    Discover    MasterCard    VISA

Card Number:  ________-_________-_________-_________   Exp. Date (mm/yy) ______/______

Signature:  ________________________________________

 

 

Your First & Last Name:

______________________________________

Address:

______________________________________

 

______________________________________

City, State, Zip:

______________________________________

Country
(if outside U.S.A.):

______________________________________

E-Mail address:

______________________________________

Daytime Phone:

(____)______________________

Evening Phone:

(____)______________________

 

Your support will help MDA continue its research and service programs for 40 different diseases. Or, you can specify a specific program or disease here:

Research Clinics Summer Camp Support Groups Duchenne MD
Amyotrophic Lateral Sclerosis (ALS) Charcot-Marie-Tooth Disease (CMT)
Spinal Muscular Atrophy (SMA)

Other  _____________________________________

If you would you like this gift to be a tribute, please answer the following:

SELECT ONE.

This gift is...
   In Memory of
   In Honor of
To Mark a Special Occasion:
   Birthday
   Graduation
   Anniversary
   Other _____________


Honoree's Name:

_____________________________________
To have notification card(s) sent, please complete the following.

I would like a notification card without the gift amount mailed to:

Name:

______________________________________

Address:

______________________________________

 

______________________________________

City, State, Zip:

______________________________________

Country (if outside U.S.A.):

______________________________________

From (Your name as you would like it to appear on the card):

______________________________________________

I would like a second notification card without the gift amount mailed to:

Name:

______________________________________

Address:

______________________________________

 

______________________________________

City, State, Zip:

______________________________________

Country (if outside U.S.A.):

______________________________________

From (Your name as you would like it to appear on the card):

______________________________________________