Please print this form, fill it out, and send along with your donation to:
Muscular Dystrophy Association – WEB
PO Box 78960
Phoenix, AZ 85062-8960

 

Payment Method:


Please select the donation amount:
 $__________    $500    $250    $100    $50    $25  

  Enclosed is my check
  Please charge my credit card or debit account using the information provided below.


 American Express    Discover    MasterCard    VISA

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

Make this a recurring donation.(Credit/Debit Cards Only)
I want to donate   Monthly   Quarterly    Semi-Annually  Annually  
Your First & Last Name: ______________________________________
Address: ______________________________________
  ______________________________________
City, State, Zip: ______________________________________
Country
(if outside U.S.A.):		 ______________________________________
E-Mail address: ______________________________________
Daytime Phone: (____)______________________
Evening Phone: (____)______________________
Send me e-mail updates on MDA research progress and events.
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): ______________________________________________