Employee Giving Form

Name

Department

Did someone refer you to the program? Yes No

Referrer Name

Select Benefit Wear Jeans Each Foundation Friday PRHF Scrub Top or Tshirt

Other Donation Amount

Do you wish to remain anonymous? Yes No

I would prefer to pay a one-time annual gift instead of a payroll deduction

By submitting this form I authorize my selected amount to be deducted from my paycheck each pay period until further notice. To discontinue my deduction I acknowledge that I must notify the Foundation Director with at least one pay period notice.

Employee Giving Form

Select 1 of the options below

Select maximum of 2 of the options below

Select maximum of 3 of the options below

Select maximum of 4 of the options below

Select maximum of 5 of the options below

*Fresh Item benefits may be delivered the Thursday before or Monday after Foundation Friday,. and can be changed upon request.

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