DC Self Defense Karate Association

Children’s Scholarship Fund

Donation Form

Name __________________________________________________________

Address ________________________________________________________

City/State/Zip ____________________________________________________

Email ___________________________________________________________

Daytime Phone (s) ________________________________________________

[ ] YES, here is my one-time donation of:

[ ]$25 [ ]$50 [ ]$75 [ ]$100 [ ]Other ______

Please submit your check – made out to the DCSDKA Scholarship Fund – with this form.

[ ] I prefer to become a member of the

Scholarship Sustainers’ Circle.

I agree to donate the monthly amount below via EFT from my bank

account, the same way I pay my DCSDKA tuition, but on the 15th

of the month. I authorize DCSDKA/Member Solutions

to deduct this amount from my bank account monthly until I request

in writing that my monthly donation be terminated.

[ ]$10 [ ]$15 [ ]$20 [ ]$25 [ ]$50 [ ] Other ______

Signed _______________________________________

Date _____________

If you wish to use an account OTHER than the one you use for tuition, please submit a voided check for that purpose.

Thank you!

Sensei Carol Middleton

DCSDKA

1716 Newton Street NW

Washington DC 20010

202-328-1203