Circle of Friends Gift Membership

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.

Melody $1,000

Harmony $2,500

Curator's $5,000

Director's $10,000

Founder's $25,000

First Name*

Last Name*

Recognize me/us in donor listings as:

I wish to keep this gift anonymous.

Address*

City*

State*

Zip*

Phone*

Email*

Confirm Email*

Yes! Sign me up to receive MIM's e-newsletters.

PAYMENT INFORMATION

Card Type*

Card Number*

Expiration Month*

Expiration Year*

Card Security Code*

RECIPIENT INFORMATION

Primary First Name*

Primary Last Name*

Other First Name

Other Last Name

Address

Phone*

E-mail

Please DO NOT notify the recipient(s) about the gift membership. It's a surprise!

ADDITIONAL INFORMATION

If you received a code, please select it here:

Additional Comments