Community Champions Pledge Form

Name*

Please enter your name as you want it to appear on donor listings.

First Middle Last

Employee Number*

Home Address*

Street Address City State ZIP Code

Entity*

Department*

Primary Phone*

Home or Cellphone

Work Phone*

I am pleased to support Med Center Health Foundation's initiative(s) as a Community Champion by pledging a donation of $1,000 per year or more.*

All donations will begin with the next pay period.

Unrestricted – Designated at the discretion of the Foundation for future healthcare initiatives
Restricted – Choose your designated Fund Choice

Gift Designation

My pledge will be in effect for the following length of time:

I pledge $38.47 to be deducted per pay period for one year (26 pay periods).

Signature*

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Comments

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Med Center Health Employees