Massachusetts CFIDS/FM Association

CHARITABLE CONTRIBUTION Form

The Massachusetts CFIDS/FM Association is dedicated to supporting research and promoting medical and public education in, and advocacy and support services for patients with Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS) of Chronic Fatigue Syndrome (CFS), Fibromyalgia Syndrome (FMS) and Myalgic Encephalomyelitis (ME).  Your tax-deductible donation will support our mission.

To make a donation to the Massachusetts CFIDS/FM Association, please complete the form below and mail it in with your donation. 

If using a credit card, please call in your card information at 617-471-5559.
 

o     Enclosed is my contribution of $_______________
 

Please make all checks payable to the Mass CFIDS/FM Association

All information on this form is kept confidential and used only for office purposes unless designated otherwise by the applicant.

PLEASE PRINT CLEARLY

Date ________________

Name _____________________________________________________________

Street___________________________________________________Apt. #_____

City ________________________________ State ______ Zip _________

Phone Number  (_____)___________________ Fax (_____)__________________

E-Mail Address _____________________________________________________

Internet Web Address _________________________________________________

Please check the appropriate boxes: I am:

o     Patient	o     Patient's Parent	o     Family Member
o     Health Care Provider	o     Other

Age ____________

Patient's Name (if different from above) _________________________________