Charity Ball 2025 Ticket Purchase

Payroll Deduction Charity Ball Reservations

For Med Center Health employees who wish to attend the Charity Ball and pay for tickets via payroll deduction.

Phone

This field is for validation purposes and should be left unchanged.

I am:(Required)

Full Time

Part Time

PRN or Temporary (not eligible for payroll deduction)

If you are a PRN and/or Temporary employee of Med Center Health, please purchase tickets by credit or debit card via the public form at the top of this page.

Employee Information

Name(Required)

First Last

Employee Number(Required)

Facility/Department(Required)

Work Phone(Required)

Cellphone or other phone you can be reached at

Work Email(Required)

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Names of guests if purchasing more than one reservation

Payroll Deduction Authorization

This is to authorize the Accounting/Payroll Department to Deduct:

Reserved Seat (1 Registrant)

Price: $250.00

Tables may be reserved for quantities of 6, 8 and 12.

Total ($250 each seat)

Split between this number of pay periods until the full amount is paid on or before the November 4, 2025 pay period.(Required)

All deductions will begin on the next pay period unless specified.

I agree to have the above listed amount paid through payroll deduction. I also understand and agree that in the event my employment with CHC (and/or its affiliated corporations) is terminated before this obligation is satisfied, CHC (and/or its affiliated corporations) may deduct any or all amounts in excess of Federal Hourly Minimum Wage from my final paycheck as consideration for payment on this account and that I will remain responsible for entire balance which will be immediately due and owing.

Signature of Employee(Required)