____________________________________________            
        Donna Reed Foundation Membership Application

        Donna Reed Foundation for the Performing Arts
             1305 Broadway, Denison, IA  51442
         Phone: (712) 263-3334  Fax: (712) 263-8026

    ___________________
    General Information

    ______________________________________________________
    Member's Name

    ______________________________________________________
    Name for First Membership Card

    ______________________________________________________
    Name for Second Membership Card (if applicable)

    ______________________________________________________
    Address

    ______________________________________________________
    City / State / Zip + 4

    ______________________________________________________
    Daytime Telephone

    ______________________________________________________
    Evening Telephone

    ______________________________________________________
    E-mail Address

    Do you want this donation listed as "anonymous"?  
    If nothing is checked, we will assume you want to be 
    listed.   [_] No    [_] Yes

    __________________
    Type of Membership

    [_] New Membership              [_] Renewal Membership  
    [_] Gift Membership

    ------------------------------------------------------

    [_] Angel                       $10,000 & above

    [_] Sponsor                     $5,000 - $9,999

    [_] Patron Circle               $1,000 - $4,999

    [_] Sustaining Member           $500 - $999

    [_] Supporting Member           $250 - $499

    [_] Contributing Member         $100 - $249

    [_] General Membership          $50

    [_] Student Membership          $35

    ------------------------------------------------------




    ______________________
    Contributions Enclosed

    Membership                      $ ____________________

    Gift Membership                 $ ____________________

    Total Amount Enclosed           $ ____________________

    ------------------------------------------------------
    ___________________
    Payment Information

    [_] My check is enclosed

    [_] Please charge to my account:

        [_] MasterCard              [_] VISA

    ______________________________________________________
    Name as it appears on card

    ______________________________________________________
    Card Number                            Expiration Date

    ______________________________________________________
    Signature

    ------------------------------------------------------
    ___________________________
    Gift Membership Information

    [_] This is a gift membership from:

    ______________________________________________________
    Donor's Name

    ______________________________________________________
    Address

    ______________________________________________________
    City / State / Zip + 4

    ______________________________________________________
    Daytime Telephone

    ______________________________________________________
    Evening Telephone

    ------------------------------------------------------

    Please return with check, money order, or credit card 
    information to:

        Membership Department
        Donna Reed Foundation for the Performing Arts
        1305 Broadway
        Denison, IA  51442   
        USA
                                                Rev. 11/01