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): YES NO

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