Make a gift in support of the Roger C. Peace Brain Injury Program

Thank you for supporting the Roger C. Peace Rehabilitation Hospital Brain Injury Program. You are helping to support the services and programs for our Brain Injury patients and their families.

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

Roger C. Peace Brain Injury 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/Campus

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)

1pay period

1pay period130pay period

Donation amount per pay period

Total number of pay periods

Total donation

Signature

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Date *

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