The Carl B. Kern Fund of The Dayton Foundation - Donor Form  

Donations can also be made online through the Foundation website (a 3.0% fee is assessed to the Fund). Go to www.kernfund.org, click on DONATE!, then click on Link for Online Donation.

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.   Cell
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 want 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.

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?
  (Use other side of printed form
  if more space is needed):
Keep these comments 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
This form and your donation will then be forwarded to The Dayton Foundation.
Thank you very much!!