Make a gift in support of the Prisma Health Pediatrics Residency Program

Thank you for supporting the Pediatrics Residency Program at Prisma Health Children’s Hospital-Upstate. You are helping to expand educational opportunities for our pediatrics and med-peds residents, all for the benefit of their patients and our community. All gifts are tax deductible.

Please complete this form to authorize payroll deductions. The anticipated start of deductions is within the next three pay periods.

For more information, please contact Cyndie Ford, Upstate Foundation, by phone at 864 797-7744 or by email at Cynthia.Ford@prismahealth.org.

Prisma Health Pediatric Residency Program 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 *

Yes, This is an honor or memorial gift

Honoree/Memorial Name:

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 = Full year)

Donation amount per pay period

Total number of pay periods

Yearly donation total

Please designate my gift to

Pediatrics Residency

Med-Peds Residency

Signature

Enter your full name to sign this form *

Date *

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