Employee Giving Campaign Form

Bristol Hospice Foundation of CA is a non-profit organization established to commit its resources to activities which are intended to ensure hospice care & other compassionate programs are available for families facing a life-limiting illness with emphasis on the underinsured/uninsured. Programs include hospice care funding & bereavement support including an annual Kids Camp for children who have experienced the loss of a love one.

Please direct questions regarding Employee Giving to California Foundation Director Cindy Lyday at cindy.lyday@bristolhospice.com or 661-716-8000.

Bristol Hospice Foundation of CA Employee Giving Pledge Form

Please select ONE of the 4 options below:

1. No Change to Current Donation

Option 1 - Please continue my current payroll deduction donation. (If you would like to continue making a donation each pay period but would like to change the amount please select and complete option #2

2. Payroll Deduction - Ongoing

Option 2 - Please deduct amount below from my wages per pay period on an ongoing basis. MUST ENTER AMOUNT

Amount

Campaign Prizes - For a donation of $10 or more please enter t-shirt size below. (NOTE: You are not eligible if you have already received a Bristol Hospice Foundation of CA teal t-shirt.)

T-Shirt Size (Option 2 with donation of $10 or more per pay period only)

3. Payroll Deduction - Set Amount

Option 3 - Please deduct the amount below for the number of pay periods indicated. (Example: If you request a $25 donation for 4 weeks your total donation would be $100) MUST ENTER AMOUNT AND NUMBER OF PAY PERIODS

Amount

AMOUNT PER PAY PERIOD

Number of Pay Periods

NUMBER OF PAY PERIODS

4. Maybe Next Time

Option 4 - I am not interested at this time. I will contact the Foundation office if I would like to participate at a later date.

Work Location *

Name *

First

Last

Signature *

Please enter the month and date of your birthday to represent your signature. This is to confirm you are the person completing this form.

Date

Comment