Team Member Engagement Payroll Deduction Form Team Member Engagement - Universal Title Mr.Ms.Mrs.MissDr.Other Title Name * Name First First Last Last Employee ID Number * Find My Employee ID Email Address * Phone Number * 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 Department/Care Division/Institute * Select a fund...Anesthesia Team Member Engagement FundCancer Team Member Engagement FundCardiology Team Member Engagement FundEmergency Medicine Team Member Engagement FundHospitalist Medicine Team Member Engagement FundMedicine SpecialtyOB/GYN Team Member Engagement FundOrthopedics Team Member Engagement FundPediatrics Team Member Engagement FundPrimary Care Team Member Engagement FundRadiology Team Member Engagement FundSurgery Team Member Engagement Fund Donation amount (per pay period) * $200$100$50$20Other Donation amount (per pay period) Enter your full name to sign this form * Date * Terms & Conditions Yes, I Agree I authorize a recurring payroll deduction in the amount indicated per pay period as my gift to the Prisma Health – Upstate Foundation. I understand that at any time, I can raise, lower or cancel my contribution by notifying the foundation via email or in writing. CAPTCHA Submit If you are human, leave this field blank.
