Inspire Courage Payroll Deduction Form - Prisma Health-Upstate Foundation

Thank you for Inspiring COURAGE. Your gift helps support the Prisma Health Children’s Hospital-Upstate Pediatric Hematology and Oncology New Inpatient Unit Campaign. With your donation, you are helping to build a world-class space within a hospital where our smallest patients and their families from across the region are provided the courage to support their treatments, medical challenges, and hospital stays.

Prisma Health Inspire Courage Payroll Deduction Authorization Form

Personal Information

Title Title

Name

First

Last

Address *

Address

Street Address

Street Address 2

City

State/Province

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

Donation amount per period

Use slider below to choose number of pay periods for deductions (26 pay periods is one full year)

Donation amount per pay period

Total number of pay periods

Total donation

Signature

Enter your full name to sign this form *

Date

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