The Carl B. Kern Fund - Donor Form  

*** SPECIAL ANNOUNCEMENT - To celebrate the Fund's 30 Years, all donations currently received - excluding estate gifts - will be MATCHED by the Fund's founder up to a total of $30,000. ***

Your Name:
Street Address, Line 1:
Street Address, Line 2, if any:
City, State/Province, Zip/Postal Code:
Preferred Phone Number, with Area Code:   Home   Bus.   Mobile
Your E-Mail Address:
Amount of Donation:$  
Would you like this gift to be anonymous?: No     Yes
If no, please list how name(s) should appear:

Please complete the information below if you would like this to be an honorary or memorial gift, which will be recognized online. You can also acknowledge this gift to individual(s) you specify plus add any comments on why you want to recognize this person. Those comments will be compiled and linked to the person's name.

This Donation is in Honor  Memory of: Name(s):  
Please acknowledge this gift to:
  (Please enter name and address. If
  you don't know the address, we'll try
  to find it - just give us a few hints!)
Any comments on why you are
recognizing this person/these people?
  (If form is printed, use other side
  if more space is needed):
Would you like these comments to be anonymous?: No     Yes
Make your check payable to: The Carl B. Kern Fund
For the most timely and accurate recording of your donation information on the Kern Fund web site,
please mail both this completed form and your check to:
The Carl B. Kern Fund; c/o Stuart Weinberg; 1207 Deanna Court; Franklin, TN 37067-8601
Your form and donation will then be forwarded to The Dayton Foundation.
Thank you very much!!