How to Make Your Contribution

							                            How to Make Your Contribution

                   Please make your tax-deductible contribution payable to
              Medical Development for Israel, Inc. (MDI) by check and return to:

                            Medical Development for Israel, Inc.
                         Schneider Children’s Medical Center of Israel
                              295 Madison Avenue, Suite 1705
                                    New York, NY 10017

                    To contribute by credit card, please call 212-759-3370

             MDI is the American fundraising organization for Schneider Children’s
              Medical Center of Israel. MDI is a 501c (3) non-profit organization.

          For more information, please call Tani Schwartz, (212) 759-3370 ext. 13
              or call toll free at (800) 556-5327 or e-mail mitzvah@mdinyc.org

     PLEASE RETURN THIS COMPLETED QUESTIONNARE WITH YOUR CONTRIBUTION
             THAT WE MAY INCLUDE YOU IN OUR ROLL OF HONOR BOOK
            KEPT AT SCHNEIDER CHILDREN’S MEDICAL CENTER OF ISRAEL.

I would like to make a contribution of $ ______

Last Name: _________________________________________

Child’s first name: _________________________________________________
                     English                          Hebrew

Mother’s First Name:_______________________________________________
                    English                          Hebrew

Father’s First Name: _______________________________________________
                    English                           Hebrew

 Female  Male

Date of bar/bat mitzvah:___________________________________________
                          Gregorian             Hebrew

Address: _______________________________________________________

City:______________________________ State:_________ Zip: __________

Phone: _______________________ E-mail: __________________________



Please indicate which project you have selected to fund: _____________________________
I heard about the Bar/Bat Mitzvah Program from:
 a friend who participated in the program  my Rabbi
 my Hebrew school teacher  an article  other __________________

Please share a quote that describes how you feel about participating in Schneider Children’s
Bar/Bat Mitzvah program (use separate sheet if necessary):




If you would like, you can also send in a picture with this form to be included in our brochure
and/or website. Please ask a parent to sign below and check off the appropriate box so that
we may use this information to inspire other children to participate in our Bar/Bat Mitzvah
Program.

I give permission for use of the following:
Full name, quote and picture in our brochure
Full name, quote and picture on our website
First name and quote on our website – please do not put full name or picture on the
internet

Signature: ______________________________________________

We would like to send a letter to your Rabbi, School Principal or Teacher acknowledging your
mitzvah. Please provide us with the name and mailing address in the space below of all the
appropriate people at your Hebrew School or Congregation that we can send this to:

Name_______________________________             Name_____________________________

Address _____________________________           Address ____________________________

City, State, Zip ________________________       City, State, Zip _______________________


I wish to EXTEND MY MITZVAH to help save children’s lives. I pledge an annual
contribution of $180 (ten times “Chai”) or more over the next five years and agree to
have my name permanently inscribed on the Roll of Honor Plaque.

Signature: ___________________________________________Date: ______________

Signature of Parent/Guardian: ____________________________Date: _____________