Please complete all fields.  When finished, simply click “send” and your form will be forwarded directly to Mt. Ida Youth and Music Ministries, Inc.  None of your information is retained by Gunblast.com, or sold to any other outside source.

Today's Date:

Last Name: First Name: Middle Initial:

Mailing Address:

City:

State: ZIP Code:

Home Phone:

Work or Other Phone:

Email Address:

Confirm Email Address:

Are you over 18 years of age? (YES or NO):

Are you a parent or grandparent? (YES or NO):

If YES, how old are your children / grandchildren (check all that apply): 0-3    4-7   8-11   12-14   15-18   19+

Amount of contribution*:     $5     $10     $20     $50     $75     $100     $150     $200     $300     $500     $1000     $1500

OTHER AMOUNT (PLEASE SPECIFY): $

* NOTE: All Contributions are tax-deductible donations to Mt. Ida Youth & Music Ministries, Inc., EIN 62-1795147

How do you want to make your contribution?

MAIL:

Mail to:    Mt. Ida Youth & Music Ministries, 869 Glenraven Drive, Clarksville, TN  37043

CREDIT CARD:

Card Type:   VISA     MC     AMEX     Discover

Card Number:

Name on card:

Expiration date:

We at Mt. Ida Youth & Music Ministries, Inc. thank you for your support. 

Please allow 4-6 weeks for contribution receipt.

 

 

 

 

 

 

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