2023 Employee Campaign
Name
*
First Name
Last Name
Employee ID Number
*
Work Email
*
example@southeasthealth.org
Department
*
Please mark one of the selections below for bi-weekly payroll deduction:
$5.00
$15.00
Other
If you selected bi-weekly giving, please select your shirt size:
S
M
L
XL
2XL
3XL
4XL
Please select which fund or service you wish to help:
ACOM Fund
ACOM Scholarship
Benevolence Fund
Cancer Services
Critical Care Unit
Emergency Services
Family Birth Center
General Purpose Fund
Heart and Vascular Services
HeartSafe Initiative
Michael Miller Memorial Scholarship
Neonatal Intensive Care (NICU)
Palliative Care
Patient Care Services
Rehab Services
Women's Health
Other donation methods:
Signature
*
Clear
Submit
Should be Empty: