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Thanks to your generous contribution, sick children and their families will be able to enjoy magical movies in an environment perfectly suited for young ones.

Name
Address
City, State, Zip

I/We wish to underwrite the cost of  _____ Chair(s). If more than two, please add a sheet for additional dedication information.

Please provide dedication information for each chair below. Please note that there is a limitation of two lines with 20 characters per line.

EXAMPLE:
In Honor of John Doe
By His Grandparents

CHAIR #1
 In Honor of
 In Memory of

By:

CHAIR #2
 In Honor of
 In Memory of

By:

 My check for (number of chairs x $500), made payable to the Health Sciences Foundation of MUSC is enclosed.

 Please charge my contribution to my:  Visa        MasterCard   

Acct. #   Expires

PRINT THIS FORM AND MAIL WITH YOUR CONTRIBUTION TO:

Health Sciences Foundation of MUSC
18 Bee Street/P. O. Box 250450
Charleston, SC 29425