Donation Form

Gift from the Heart to Duchenne Muscular Dystrophy Research Fund (DMDfund)
(To print this form, only, click on the text and then use your normal print options)

Please print and use this form for contributions, memorial gifts, or for honoring your friends
and family on special occasions. A beautiful card will be sent to them in your name.

All contributions are tax-deductible as allowed by law.

Once completed, mail this form and and donation gift to:
DMDfund • PO Box 17371 • Encino, CA 91416

Please accept my tax deductible contribution of $___________

___ Check Enclosed (Please make payable to "DMDfund". )

___ VISA or ___ MasterCard

|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| exp. ___/___

Signature (as it appears on your credit card)

Your Name: ___________________________________________________________

Address: _____________________________________________________________

City: ____________________________ State __________ Zip __________

E-mail Address: _____________________________________________ (To be held in privacy)

My gift is made: in memory of: _________________________________________________________

in honor of: _________________________ for the occasion of ________________________________

Please Notify :

Name _____________________________________________

Address ___________________________________________

City _____________________________ State ____________ Zip __________

|___| I've enclosed my statement of sentiment and support for the kids & families with DMD.
You have my permission to include these in the DMDfund website Hearts of Gold register.
Please send me a link at ____________________________________ (address will be held in privacy)

...We thank you for your generosity... and for remembering... your heart is a muscle too!

Kyle Kyllan • • PO Box 17371 - Encino, CA 91416 • 818-692-5500