Team Member Giving Payroll Deduction Form PHUF 2026 Team Member Giving Campaign – Payroll Deduction Personal Information Title Mr.Ms.Mrs.MissDr.Other Title Name * Name First First Last Last Address * Address Street Address Street Address Street Address 2 Street Address 2 City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email Address * Phone Number * Work Information Employee Number * Department Name * Hospital/Dept Number If you are on the Prisma Health Network, find your Employee ID Number Here. If you are not on the network, your Employee ID Number can be found on Workday under your “Job Details” page. Donation Information Gift Designation * Please make one selection:Catalyst FundHelp Greer GrowHelp Fountain Inn Grow Donation amount per period * $ We hope you will consider joining our Upstate CEOs leadership giving level, Elevate, with a gift of $38.47 per pay period Use slider below to choose number of pay periods for deductions (26 pay periods is one full year) * 12626 Donation amount per pay period $ Total number of pay periods Total donation $ Signature Enter your full name to sign this form * Date * CAPTCHA Submit If you are human, leave this field blank.
