Circle of Friends Membership

 

RECURRING PAYMENT

 

 

MIM is a registered 501(c)3 nonprofit organization.

Please complete the form below and click "Submit" to confirm your membership.

 

To submit this form, all "*" fields must be filled in. 

   

Duo $100 $8.30 monthly   or $25 quarterly
Family $150 $12.50 monthly   or $37.50 quarterly
Song $250 $21 monthly   or $62.50 quarterly
Rhythm $500 $42 monthly   or $125 quarterly

 

Recurring Amount*
Frequency*

MEMBER INFORMATION
Primary First Name*
Primary Last Name*
Other First Name
Other Last Name
Recognize me/us in donor listings as:
I wish to keep my/our gift anonymous.
Address*
City*
State*
Zip*
Phone*
Email*
Confirm Email*
Sign me up to receive MIM's e-newsletters.
PAYMENT INFORMATION
Card Type*
Card Number*
Expiration Month*
Expiration Year*
Card Security Code*
ADDITIONAL INFORMATION
Additional Comments