2019-2020 Annual Giving Form

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* 1. First Name

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* 2. Last Name

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* 3. Employee #

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* 4. Department

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* 5. Your Recurring Gift

60 Minute Club (60 minutes of pay per pay period will be payroll deducted)

30 Minute Club (30 minutes of pay per pay period will be payroll deducted)

$5 Dollars-A-Week-Club ($260 annual gift payroll deducted at $10 per pay period)

Dollar-A-Day-Club ($365 annual gift payroll deducted at $14.04 per pay period)

Dollar-A-Week-Club ($52 annual gift payroll deducted at $2 per pay period)

Recurring Gift (The amount that you specify below will be payroll deducted EACH pay period)

One-Time Non-recurring Gift (The amount that you specify below will be payroll deducted once)

Please specify the $ amount you would like deducted for your one time payment or recurring payment.

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* 6. Please select a fund or endowment

Unrestricted funds

Education

Facilities

Community Outreach (CMC Smart Snacks, Healthreach, Diabetes Initiative, Mammography Initiative, Colon Cancer Initiative, Cardiac Program)

Patient Care

Employee Assistance

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* 7. Authorization

By checking this box, I authorize Conway Medical Center Foundation to deduct the amount I have selected from each paycheck. I understand that this authorization continues unless otherwise specified by me in writing. I understand that all personal information will be kept confidential.