MDA Help Now

Printable Donation Form

Please print this form, fill it out, and send along with your donation to:
Muscular Dystrophy Association - LEGACY RIDE
c/o West America Bank
790 W. Shaw Avenue
Fresno, CA 93704
If your donation with this form is received by July 15th, 2003
it goes towards The Legacy Ride's eligilbilty for the Parade of MDA Heroes

Payment Method:

Enclosed is my check PAYABLE TO MDA
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) ______/______ 
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): ______________________________________________